NEW Looking Towards 2015 HIV Gender

UNICEF/Graeme Williams
Looking towards 2015:

Breakthrough Strategies for Women, Girls,
Gender Equality and HIV in Eastern and Southern Africa
Foreword
Foreword
Eastern and southern Africa is the region most affected by HIV. The face of the
epidemic continues to be female and, in particular, a young girl. This is not new.
We have spoken about this repeatedly and have made calls for exerted efforts
and accelerated action. But the one thing that has remained resilient over the
past 30 years of the epidemic is the disproportionally higher levels of infection
among women and girls.
Young women are particularly vulnerable to HIV, accounting for 64 per cent of infections among young people worldwide. In sub-Saharan Africa, young women
make up to 71 per cent of young people living with HIV. Moreover, we know that
HIV is contributing significantly to maternal and child mortality, particularly in the
hyper-endemic countries in southern Africa. This is an unacceptable and unjust situation. Human rights and gender equity cannot be separated from HIV prevention,
treatment and care, and we must instinctively understand that the AIDS response
must be rights-based.
Over the last decades, countries within the region have obligated themselves to
tackle the impact of HIV and AIDS and notable achievements have been made, in
line with the Millennium Development Goals (MDGs). However, despite the progress,
there is an urgent need for cutting-edge responses to address the existing gaps in
Universal Access for women and girls. Countries have made clear commitments to
eliminate gender inequality and gender-based violence, and to increase the capacity of women and adolescent girls to protect themselves from HIV infection. None
of these ambitious targets can be achieved without working in joint partnership,
clearly defining our roles and active participate in the AIDS response.
It gives us great pleasure to present this series of papers to you. It provides a snapshot of the current situation, highlighting gaps and challenges. Furthermore, it presents new, cutting edge recommendations on priority actions up to 2015, which
will make a real difference in tackling the identified challenges. The papers have
been developed by technical teams and are a joint United Nations effort, leveraging the comparative advantage of each UN agency to harness the best results. This
series will serve as a valuable resource for governments, policy makers, academic,
civil society and others who work tirelessly to turn the epidemic around, with highimpact interventions that have proven positive impacts for people affected by HIV
and AIDS, women and girls in particular.
Elhadj As Sy, Director of UNICEFs Eastern and Southern Africa Regional Office (ESARO)
Sheila Tlou, Regional Director, UNAIDS Regional Support Team for Eastern and Southern
Africa (RST ESA)
Nomcebo Manzini, Southern Africa Regional Director, UN Women
Edwin Huizing, Director Subregional Office East and Southern Africa, United Nations
Population Fund (UNFPA).
Contents
Contents
Foreword 1
Acronyms and abbreviations
Acknowledgements 6
1. Introduction
1.1 Strategic recommendations
1.2 Conclusion
1.3 References
8
11
12
12
2. The law, gender and HIV

2.1 Introduction
2.2 International legal frameworks for women, girls and HIV
2.3 Key challenges and ways to address them
2.4 Guiding principles for future action
2.5 Recommendations
2.6 Conclusion
2.7 References
13
13
14
15
19
21
23
23
3. Sexual and reproductive health, gender and HIV:

post-Maputo progress made towards universal
access and the MDGs
3.1 Introduction
3.2 International agreements
3.3 African legal instruments
3.4 The Maputo Plan of Action
3.5 Review of progress since Maputo
3.6 Recommendations
3.7 Conclusion
3.8 References
26
26
26
27
27
28
31
31
32
4. HIV prevention, women, girls and gender equality

4.1 Introduction
4.2 Factors driving vulnerability in women and girls
4.3 Barriers to effective prevention
4.4 Protecting women and girls from HIV
4.5 Revolutionizing HIV prevention
4.6 Recommendations
4.7 Conclusion
4.8 References
33
33
34
35
36
37
38
40
40
5. Adopting a multi-stakeholder approach to

address violence against women and HIV
5.1 Introduction
5.2 Challenges and opportunities
5.3 Recommendations
5.4 Conclusion
5.5 References
41
41
44
46
47
47
Contents
6. HIV treatment and care: the concerns for women

and girls
6.1 Introduction
6.2 Regional challenges and issues
6.3 Recommendations
6.4 Conclusion
6.5 References
48
48
49
55
56
56
7. Engaging men as partners in addressing gender

inequality and HIV
7.1 Introduction
7.2 Factors underlying women and mens vulnerabilities to HIV
7.3 Changing gender norms
7.4 Review of programmes that engage men in addressing gender and HIV
7.5 Recommendations
7.6 Conclusion
7.7 References
58
58
59
61
62
64
65
65
Annex 1. Draft Windhoek Declaration on Women, Girls,

Gender Equality and HIV: Progress towards
Universal Access
67
Acronyms and
abbreviations
(a.i.)
ad interim (temporary, acting)

ADB
African Development Bank
AIDS
acquired immune deficiency syndrome
ANC
antenatal care
ART
antiretroviral therapy
ARV antiretroviral
AU
African Union (previously known as Organisation of the

African Union, OAU)
CAPRISA
Centre for the AIDS Programme Research in South Africa
CBO
community-based organization
CD4
Cluster Difference 4
CEDAW
Convention on the Elimination of All Forms of

Discrimination against Women
CHBC
comprehensive home-based care
COMESA
Common Market for Eastern and Southern Africa
COVAW
Coalition to End Violence Against Women
CSE
comprehensive sexuality education
DHS
Demographic Health Survey
EAC
East African Community
ECA
Economic Commission for Africa
eMTCT
elimination of mother-to-child HIV transmission
ESARO
Eastern and Southern Africa Regional Office
FAAS
Forum Against the AIDS Scourge
GBV
gender-based violence
GCWA
Global Coalition on Women and AIDS
GEM
Gender Equitable Men
GEMSA
Gender and Media Southern Africa
HIV
human immunodeficiency virus
HIV-APCoP
Asia Pacific Community of Practice on HIV, Gender and

Human Rights
HPTN
HIV Prevention Trials Network
HSV-2
herpes simplex virus 2
HTC
HIV testing and counselling
ICHRP
International Council on Human Rights Policy
ICPD
International Conference on Population and Development
ICRW
International Center for Research on Women
IDLO
International Development Law Organization
ILO
International Labour Organization
IMAGE
Intervention with Microfinance for AIDS and Gender Equity
IMAGES
International Men and Gender Equality Survey

IPU
Inter-Parliamentary Union
KELIN
Kenya Ethical and Legal Issues Network on HIV and AIDS
MDGs
Millennium Development Goals
MIC
Multiple Indicator Cluster (survey)
MPH
Master of Public Health
MPoA
Maputo Plan of Action on Sexual and Reproductive

Health and Rights
MSM
men who have sex with men
NASA
National AIDS Spending Assessment
NEPAD
New Partnership for Africas Development
NVP nevirapine
OECD
Organization for Economic Co-operation and Development
OSISA
Open Society Initiative for Southern Africa
PEPFAR
United States Presidents Emergency Plan for AIDS Relief
PhD
Doctor of Philosophy
PMTCT
prevention of mother-to-child transmission
PrEP
pre-exposure prophylaxis
RATESA
UN Regional AIDS Team for Eastern and Southern Africa
RST ESA
(UNAIDS) Regional Support Team for Eastern and Southern Africa
SADC
Southern African Development Community
SAfAIDS
Southern African AIDS Information Dissemination Service
SBCC
social and behaviour change communication
Sida
Swedish International Development Cooperation Agency
SMART
specific, measurable, achievable, relevant, and time-based
SMS
short message service
SRHR
sexual reproductive health and rights
STI
sexually-transmitted infection
UN
United Nations
UNAIDS
Joint United Nations Programme on HIV and AIDS
UNDP
United Nations Development Programme
UNESCO
United Nations Educational, Scientific and Cultural Organization
UNFPA
United Nations Population Fund
UNGASS
United Nations General Assembly Special Session in HIV/AIDS
UNICEF
United Nations Childrens Fund
UNIFEM
United Nations Development Fund for Women
VAW
violence against women
VSO RAISA
Voluntary Service Overseas Regional AIDS Initiative of Southern Africa
WfC
Women for Change
WHO
World Health Organization
Acknowledgements
Acknowledgements
We would like to express our appreciation to the members of the High Level Task
Force for Women, Girls, Gender Equality and HIV chaired by Dr Fatma Mrisho,
National AIDS Council, Tanzania with vice-chair Honourable Naomi Shaban,
Minister of Gender, Kenya and the participants at Windhoek technical meeting
in April 2011 for their commitment and for initiating the process leading to the
development of the papers.
We are indebted to members of the Regional Economic Commissions: the East
African Community (EAC); the Common Market for Eastern and Southern Africa
(COMESA); and the Southern African Development Community (SADC). Furthermore,
we thank the UN Regional AIDS Team for Eastern and Southern Africa (RATESA), especially UNAIDS, UNDP, UNICEF, UNFPA and UN Women, for the numerous insights
gleaned over the last few weeks.
We would also like to extend special thanks to the technical team for the immense
support it has provided in the compilation and coordination of the various papers.
The efficiency and joint UN spirit displayed by the technical team should be seen
as an inspiration for future joint activities to come.
We thank Josee Koch (UNICEF ESARO) and Amakobe Sande (UNAIDS RST ESA) for
their joint work in coordinating the entire development of these technical papers
and for pulling together the Introduction and editing all technical papers. Thanks
also to the following technical lead authors and peer-reviewers for their valuable
feedback and input into the technical papers:
The paper on The law, gender and HIV was developed under the technical lead of
Susana Fried, Cluster Leader (a.i.): Mainstreaming, Gender and the MDGs and Senior
Gender Advisor, UNDP and peer reviewed by:

Sofia Gruskin, director of the Program on Global Health and Human Rights at
the University of Southern Californias Institute for Global Health; Professor of
Preventive Medicine at the Keck School of Medicine; and Professor of Law and
Preventive Medicine at the Gould School of Law;
Monica Tabengwa, expert in human rights training and research, democracy

and governance and legislative reform; and
Mandeep Dhaliwal, Cluster Leader: Gender, Human Rights & Sexual Diversities
UNDP HIV/AIDS Practice Bureau for Development Policy.
The paper on Sexual and reproductive health, gender and HIV: post Maputo
progress made towards universal access and the MDGs was developed under
the technical lead of Dr Margaret Agama, Regional HIV and AIDS Adviser, UNFPA,
and Dr Kanyanta Sunkutu, Programme Specialist, UNPFA, and peer reviewed by:
Dr Sihaka Tsemo, Senior Legal, Gender and Human Right Expert.
The paper on HIV prevention, women, girls and gender equality was developed
under the technical lead of Helen Jackson, Senior HIV Prevention Advisor, UNAIDS
RST ESA, and peer reviewed by:

Samantha Willan, HIV and gender specialist and based in South Africa; and
Sara Page-Mtongiwza, Deputy Director, Southern Africa HIV and AIDS Information Dissemination Service (SAfAIDS).
Acknowledgements
The paper on Adopting a multi-stakeholder approach to address violence against women and HIV
was developed under the technical lead of Susan Kimathi, Regional Programme Officer, UN Women and
peer reviewed by:

Evelyn Serima, HIV and AIDS Technical Specialist, International Labour Organisation (ILO);
Philippe Denis, Professor at the University of KwaZulu-Natal, South Africa, and Director of the Sinomlando Centre for Oral History and Memory Work in Africa; and
Dr Vicci Tallis, Programme Manager: HIV and AIDS, Open Society Initiative for Southern Africa (OSISA).
The paper on HIV treatment and care: the concerns for women and girls was developed under the
technical lead of Josee Koch, Regional Knowledge Management Specialist, UNICEF ESARO and peer reviewed by:
Dr Brian Pazvakavambwa, World Health Organisation Regional Office for Africa (AFRO); and

Bongai Mundeta, Director of Voluntary Service Overseas Regional AIDS Initiative of Southern Africa
(VSO RAISA) and Dr Sandra Musengi, expert in HIV care and support, VSO RAISA.
The paper on Engaging men as partners: involving men in addressing gender inequality and HIV
was developed under the technical lead of Lydia Mafhoko Ditsa, UNDP, and peer reviewed by:

Sofia Gruskin, director of the Program on Global Health and Human Rights at the University of Southern
Californias Institute for Global Health, Professor of Preventive Medicine at the Keck School of Medicine
and Professor of Law and Preventive Medicine at the Gould School of Law.
Finally, we would like to express sincere gratitude for the financial assistance of the Swedish International
Development Cooperation Agency (Sida) for its continuous support to the work of the High Level Task
Force for Women, Girls, Gender and HIV. The commitment shown by Sida to womens rights and gender
equality particularly in the context of the HIV epidemic is a testament to the important role that development cooperation partners can play in the social development of the region.
Introduction
Introduction
Women and girls constitute the majority (over 60 per cent) of people living
with HIV and AIDS in sub-Saharan Africa. In some countries, young women and
girls (aged 15 to 24 years) are six times more likely to be infected by HIV than
men and boys of the same age. A combination of biological, behavioural and
structural issues contributes to heightened vulnerabilities of females to HIV and
its impacts. Women and girls bear a disproportionate burden of the impacts of
HIV through their traditional familial and community responsibilities: not only
do females take more responsibility for caring for the sick and mitigating the
impacts of HIV in families and communities, but also, when they learn about (and
disclose) their HIV status, they suffer more violence, ostracism and destitution
than males in the same situation.
Despite growing evidence and awareness of the intricate links between gender
inequalities and vulnerability to HIV and its impacts, policy makers and programme
implementers have not made substantive progress in addressing these issues. It is
now widely acknowledged that the Millennium Development Goals (MDGs) will not
be attained (in particular MDG 6: reversing and halting the HIV epidemic), unless
policy makers and programme implementers undertake a series of accelerated,
scaled-up actions to comprehensively address gender inequality.
The situation is not all doom and gloom: governments should be credited for the
many international, regional and national political commitments in this area. International agreements include the Convention on the Elimination of All Forms of Discrimination against Women (1979), the Programme of Action of the UN International
Conference on Population and Development (ICPD, 1994), the Beijing Declaration
and Platform for Action (1995), and the United Nations Declarations on HIV and AIDS
made at the UN General Assembly in 2006 and 2011.
Bold and ambitious declarations have also been made at continental and regional
levels. These include the AU Solemn Protocol and Solemn Declaration, the SADC
protocol on Gender and Development and the Maputo Plan of Action, among others. As instruments towards which governments can aspire and be held accountable,
these commitments are a step in the right direction. Many countries in eastern and
southern Africa can be credited with having sound, evidence-informed policies
and legislations around gender equality and HIV. However these documents have
not yet been translated into meaningful scaled-up action to address the rights and
need of women and girls in the context of HIV.
Given the urgent necessity of addressing this in sub-Saharan Africa, the Southern
African Development Community (SADC), East African Community (EAC) and Common Market for Eastern and Southern Africa (COMESA) convened a regional High
Level Meeting on Women, Girls, Gender Equality and HIV, which was held in Namibia
in April 2011, with UN support. The meeting was part of a process that lead to African
Ministers of Health agreeing an African Common Position at the African Union, in
preparation for the United Nations General Assembly High Level Meeting on HIV
and AIDS held in June, 2011.
Participants at the Windhoek High Level Meeting included government representatives, parliamentarians, and members of civil society organisations drawn from the
Member States of the three Regional Economic Commissions. The meeting reviewed
progress and barriers to universal access and deliberated on breakthrough strategies
that address the vulnerabilities of women and girls and lead to female empower-
Introduction
ment and gender equality, in order to achieve international goals on universal access and 50 per cent
reduction in HIV transmission by 2015.
To guide discussions at the women and girls meeting, six technical papers were presented and deliberated
upon focusing on critical areas around which further progress is still required and discussions resulted in
delegates agreeing a Draft Windhoek Declaration on Women, Girls Gender Equality and HIV: Progress towards
Universal Access (attached as Annex 1)1
These papers form the basis for this publication.
The first paper, The law, gender and HIV, provides an overview of international and regional commitments and declarations made in this area. The paper is important because it draws attention to structural
determinants of HIV which have not yet received adequate attention, particularly from the perspective of
developing enabling legal and policy environments. It reviews bottlenecks to progress such as harmful
traditional and cultural practices, inequalities entrenched in family law (including property rights) and
punitive laws that increase womens risk and vulnerabilities. The paper also addresses shortcomings of
governments in the region which have good gender equity laws but do not exercise due diligence in
enforcing them. With examples of best practice from across the globe, it makes recommendations for legal
reform, using alternative (and traditionally-based) dispute resolution mechanisms, repealing discriminatory
laws, and scaling up access to justice.
The paper on Sexual and reproductive health, gender and HIV: post-Maputo progress made towards
universal access and the MDGs, takes stock of the eastern and southern Africa regions implementation
of the Maputo Plan of Action (MPoA). This paper very poignantly points to critical implementation failures
in ensuring that
African Governments, civil society, the private sector and all development partners redouble their
efforts so that the effective implementation of the continental policy [Framework for Sexual and
Reproductive Health and Rights], including universal access to sexual and reproductive health by
2015 in all countries in Africa, is achieved.
(African Union, 2006)
The MPoA called for scaled-up action and policy alignment to integrate sexual and reproductive health
(SRH) into primary health care, repositioning family planning and closing the huge gap in contraceptive
use, developing and promoting youth-friendly services, addressing unsafe abortions, promoting safe
motherhood, ensuring commodity security and strengthening monitoring and evaluation. The review
found an unprecedented momentum in aligning national policies and strategies to meet international
targets including universal access and the Millennium Development Goals. However, implementation has
lagged behind, with few exceptions. Although an enabling policy environment is important and evidenceinformed planning is critical, real progress in newborn, child and womens health can only be made by
implementing effective priority actions, and monitoring them to track progress and adapt implementation to dynamic contexts as needed. Emerging recommendations included the urgent need for countries
to meet the continental target of allocating 15 per cent of national budgets towards health services (as
pioneered by Botswana in fulfilment of the Abuja Declaration of 2001); strengthening operational research
and data gathering and analysis; aligning national legislation in accordance with African and international
commitments; and strengthening and mainstreaming rights-based and gender equality actions into other
health and development policies and programming.
For a region that has 60 per cent of the HIV burden of the global epidemic and only ten per cent of global
HIV expenditure, turning off the tap of new HIV infections has never been more critical. The technical
paper on HIV prevention, women, girls and gender equality makes a strong case for stopping blanket,
population-based HIV prevention strategies and prioritising efforts where the most new infections are
occurring. Although HIV prevention efforts are beginning to yield positive results some 22 countries in
Eastern and Southern Africa have reduced HIV incidence by over 25 per cent from 2001 to 2009 (United
Nations Secretary-General, March 2011) the paper laments the fact that political commitment, financing
1. The declaration is still in draft form because it requires tabling at an official meeting of the sub-regional entities in the region.
10
Introduction
and programming for HIV prevention has lagged behind treatment and care. Thus the investment strategy
for countries in the region is fundamentally flawed and unsustainable because, as the evidence shows, for
every two people put on treatment, another five become newly infected.
Key areas that require urgent prioritization to address immediate risk factors are: reducing age-disparate
sex, number of sexual partnerships and concurrency; the implementation of wide-scale medical male
circumcision; and interventions that delay sexual debut and support consistent male and female condom
use. Protecting women and girls from HIV requires interrelated combination approaches. More importantly,
strategies must prioritize groups most at risk and where the incidence is highest.
For young people, the paper also deplores the moralisation intransigence in the region around sexuality education. It recommends scaling up rights-based, scientifically accurate and grounded in evidence,
culturally appropriate, age specific, and comprehensive sexuality education programmes, which are part
and parcel of mainstream, examinable education and teaching curricula.
An examination of the critical barriers to Universal Access for women and girls in the context of HIV and
AIDS in eastern and southern Africa is incomplete without an examination of the high levels of genderbased violence in the region. Once again, this region must be commended for demonstrating willingness
to address violence against women (VAW) and HIV. This is evident from the number of countries that has
assented to international, continental and regional commitments and successfully promulgated laws and
developed policies in this respect.
The technical paper in this series that addresses this area very aptly looks at Adopting a multi-stakeholder
approach to address violence against women and HIV as an important strategy. Using the Kabber
framework and citing a series of studies and impact evaluations, the paper vividly demonstrates how
implementation in this area has failed to achieve desired results owing to fragmentation in addressing
the holistic, multisectoral and multi-faceted needs of survivors of violence. More importantly, it reviews
the challenges that governments in the region have had to prevent violence from occurring in the first
place. Resources allocated to programmes that prevent both primary and secondary violence are woefully inadequate, programmes that empower women are not implemented at large enough scale, men
and boys have been on the periphery of many programmes and were not viewed as critical enablers for
change (or not until recently), and in most countries, programmes to address VAW are being implemented
vertically. Systematic integration and the provision of comprehensive services are still challenges. There
are a lot of missed opportunities in this area that can be seized upon and lessons can be learned from
independently evaluated effective programmes (such as Stepping Stones, Thuthuzela and MenEngage)
that provide examples of actions that governments can take at scale to address violence against women.
In the area of treatment and care, women and girls undoubtedly benefit the most and in every country in
the region (without exception), they are the majority of people accessing antiretroviral therapy (ART). This
has however not come without its challenges. As majority beneficiaries of these programmes, they are the
ones who have had to deal the most with stigma and discrimination and the impacts of disclosure. Being
the first to know their status (as part of ante-natal care and prevention of mother-to-child transmission
services) has meant that they have then had to carry the triple burden of finding out their status first, worrying about disclosure and worrying about the impact of their status on their unborn children. Therefore the
benefits of treatment have come at a great price. As the paper on HIV treatment and care: the concerns
for women and girls shows, the challenges in this area that must be addressed as a matter of priority are:
1. the sexual and reproductive health and rights (SRHR) of women living with HIV and, in particular,
their disproportionately high vulnerability (as a result of their HIV status) to reproductive cancers;
2. the policy and implementation gaps in support of HIV-positive adolescents in both health and nonhealth settings and exploring low-cost models for transitioning adolescents from paediatric HIV care
to adult care; and
3. the urgent need to scale up mens interest in and access to testing and counselling services (linked
to treatment and their SRH needs). While mens access to HTC and ART has been neglected in the
past, recent evidence around treatment for prevention and the benefits of male circumcision is
showing the need to focus on this area for the double benefits of better health outcomes for men
in their own right, as well as extended benefits for their sexual partners in the long term.
11
Introduction
The last paper in this series looks at Engaging men as partners: involving men in addressing gender inequality and HIV. When one looks at the very limited progress attained for women and girls in the context
of HIV, one has to ask whether, in this particular respect, the models adopted for womens empowerment,
which focused primarily on women and excluded and alienated men were not counter-productive. This
paper makes a strong case for building solidarity between men and women towards gender equality as
instrumental in curbing HIV infections. On the basis of extensive population-based impact evaluations of
programmes such as Stepping Stones and Soul City, it recommends wider scale programmes to counter
the limited, and often harmful, set of roles and behaviours for men. Such programmes will get them to
work with women for gender equality, to question harmful definitions of masculinity and to challenge
harmful gender norms. The paper further demonstrates the importance of men who hold leadership positions in actively influencing policy and programme development and in harnessing gender-transformative
programmes. Its core message is that work to engage men must be supportive of and not counter to
efforts to empower women and girls.
1.1 Strategic recommendations
A review of all the technical papers yields a number of recommendations within each area, but each paper
also highlights straightforward, easy-to-implement breakthrough strategies which shockingly still have
not been implemented 30 years into the AIDS epidemic. These common themes run across all the papers
and form the basis of the Draft Windhoek Declaration on Women, Girls Gender Equality and HIV: Progress
towards Universal Access. They are all intricately linked to each other, and the key ones are:
1.1.1 Stop shooting in the dark
It is disheartening to find that, 30 years into the epidemic, there are still cases where we do not have data
disaggregated by sex (and other variables) to guide national HIV and AIDS responses. Furthermore, often
where appropriate data exist, they are not used to inform policy and planning. Even more disturbing is the
fact that the evidence for what is working is not utilised to leverage wider impacts. Hence it is critical to
gather age and sex disaggregated data systematically and consistently, to conduct robust gender analysis
at national levels and within HIV hotspots, and use this evidence to guide policy and programming.
1.1.2 Show me the money
Although there is evidence that national planning documents in the region are increasingly informed by
evidence (from modes of transmission studies and other recent HIV research), many strategies extol the
values of gender-sensitive and human rights approaches but then fail to link evidence and analysis to
actionable and costed programmes. In most cases it is difficult to identify what money has been allocated
to and spent on women, girls, gender equality and HIV. In order to rectify this, data must be disaggregated
and clear budget lines on women, girls, gender equality and HIV identified and tracked, in order to enable
clear accountability in National AIDS Spending Assessments and National Health Accounts.
1.1.3 Only a well signposted road will get you there
A review of progress towards the international and regional commitments on HIV and AIDS demonstrates
our inability to measure changes (whether positive or negative) in this area. This is because gender equality and HIV targets are not as clearly defined, nor as easy to measure as the numeric targets agreed upon
for HIV treatment, prevention and resource mobilisation. This may be attributable partly to the fact that
badly-needed data is missing (Carael, Marais, Polsky, & Mendoza, 2009) in so many areas and there are no
clear baseline data to inform target setting. Countries must set clear, ambitious and measurable national
targets to monitor progress and impact for women, girls, gender equality and HIV.
12
Introduction
1.1.4 Brothers and sisters for life
Men are often overlooked in gender equity and equality programmes, yet they can play a crucial role in
influencing gender norms, such as upholding traditions that can limit womens power, as well as beliefs
that can put mens and womens health at risk (and risk the health of entire families). Fostering solidarity
between men and women towards gender equality (including social transformation to challenge harmful gender norms) is instrumental in curbing HIV infections. Programmes that engage men in becoming
agents for change, taking responsibility for HIV prevention, treatment and care, and addressing harmful
gender norms and gender-based violence should be intensified.
1.1.5 As if women matter
Finally and most importantly, it is evident that visionary leadership understands that gender equality is a
necessary condition for development. Where every possible measure has been taken to root out gender
inequality, positive health and development outcomes have naturally followed. Leadership in the region
should start to hold programme implementers accountable for showing results in the area of gender
equality and HIV.
1.2 Conclusion
As Rao Gupta and colleagues have pointed out, it is tragic that, while much is known, and effective
strategies exist, implementation does not match the evidence. (Gupta, Ogden, & Warner, 2011) Impact at
population level will not be achieved unless gender considerations are integrated into evidence-informed,
comprehensive national strategies. Such strategies must be implemented by national governments within
an enabling policy and legal environment, and change must be driven and owned by leaders and communities alike (including people living with HIV as equal partners) who are empowered with skills and
resources.
1.3 References
African Union. (2006). Maputo Plan of Action for the Operationalization of the Continental Policy Framework for
Sexual and Reproductive Health and Rights 20072010. Addis Abbaba: African Union.
Carael, M., Marais, H., Polsky, J., & Mendoza, A. (2009, Dec). Is there a gender gap in the HIV response? Evaluating
national HIV responses from the UN General Assembly Special Session on HIV/AIDS Country Reports. J Acquir
Immune Defic Syndr., 52 Suppl 2, pp. S1118.
Gupta, R., Ogden, J., & Warner, A. (2011, October). Moving Forward on Womens Gender Related HIV Vulnerability:
The Good News, the Bad News and What to do About it. Global Public Health, 6, pp. S370S382.
United Nations Secretary-General. (March 2011). Uniting for Universal Access: towards zero new HIV infections,
zero discrimination and zero AIDS-related deaths. UNGASS Agenda Item 10: Implementation of Declaration of
Commitment on HIV/AIDS and the Political Declaration on HIV/AIDS. New York: United Nations.
The law, gender and HIV
The law, gender

and HIV
2.1 Introduction
Over the past few decades, progress has been made in addressing the linkages
between gender inequality and HIV. Emerging, more multi-layered understanding has helped to expand action to address the gender dimensions of HIV. It
has also helped to strengthen attention to the needs and rights of women and
girls in the context of HIV, as well as the needs and rights of men who have sex
with men, sex workers and transgender persons. Increasingly, this perspective
draws attention to discrimination, harmful gender norms1 and punitive laws
and policies which are drivers of HIV and are barriers to effective responses
(UNAIDS, 2010).
Gender inequality acts as a main driver of the AIDS epidemic, resulting in heightened risk of contracting HIV for both men and women (Gupta G. R., 2000) (Gupta,
Parkhurst, Ogden, Aggleton, & Mahal, 2008). Gender inequality also generates an
intensified burden for women and girls in managing the impact of HIV, especially
at the household and community levels (HIVAPCoP web site). At the same time,
the ability to challenge inequality and discrimination and the capacity to counter
punitive laws and policies is also connected to gender inequality. Discrimination
exacerbates the effects of HIV, resulting in inequitable impact on those who are
already most disempowered legally and socially marginalized. In general, women
and girls disproportionately feel these inequalities related to HIV worldwide, especially in eastern and southern Africa (ESA), where women constitute 60 per cent of
people living with HIV (UNAIDS RST ESA web site, 2009).
Our discussion of gender, HIV and the law in this technical paper focuses primarily
on women and girls. However, it is important to note that gender is a broader concept, encompassing the widely held beliefs, expectations, customs and practices
within a society that defines masculine and feminine attributes, behaviours and
roles and responsibilities (UNAIDS, 2011). It refers to a set of power relations between
and among women and men, inclusive of men who have sex with men, gay men,
lesbians and other women who have sex with women, and transgender persons.2
The HIV epidemic flourishes in contexts of inequality. As a result, women and girls
as well as men who have sex with men and transgender persons are rendered
even more vulnerable to rights violations. Marginalized women and men (including
sex workers, women and girls from racial and ethnic minorities, indigenous women
and girls, domestic and migrant workers, women in conflict settings, women and
1. Gender norms refer to learned and evolving beliefs and customs in a society that defines what is socially acceptable in terms of
roles, behaviours and status for both men and women. In the context of the HIV epidemic, these gender norms strongly influence both
mens and womens risk-taking behaviour, expression of sexuality, and vulnerability to HIV infection and impact, including their ability
to take up and use HIV prevention information and commodities, as well as HIV treatment, care and support. Gender norms can also
be the basis of discrimination and violence against men who have sex with men, lesbians and transgendered people, placing them
at higher risk of HIV infection and impact.
2. We recognize that gender encompasses men and women in all their diversity. While gender norms can be harmful to women and
girls, they also negatively impact men and boys. The way many cultures define masculinity can dictate a limited and often harmful
set of acceptable behaviours for men. These include sexual aggression, risk taking and multiple sexual relationships, thus increasing
their risk and vulnerability to contracting HIV. Furthermore, men who do not conform to social norms of masculinity may be targeted
for gender-based discrimination and violence.
UNICEF/Karin Schermbrucker
13
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girls living with HIV, lesbians, women in prison, drug users, etc.) are often targets of violence, including
rape, and are at high risk for HIV.
Womens disadvantaged social and economic status in families, communities and countries is often reinforced by widespread discrimination in statutory or civil law. In some cases, women are considered to be
legal minors or do not have equivalent citizenship rights as men have. However, even with full citizenship
de jure, women and girls are frequently excluded from decision-making processes and subjected to high
levels of physical and sexual violence verging on extreme levels in conflict contexts.
From the perspective of gender, HIV and the law, gender inequalities can be considered in five overlapping
areas: 1) restricted social and economic rights; 2) gender-biased family law; 3) punitive laws and policies;
4) lack of protection of bodily integrity; and 5) unimplemented laws. In each of these categories, issues
of access to justice whether in formal or informal contexts is a persistent challenge. Legal and policy
environments that diminish womens rights and put their physical and economic security in jeopardy
exacerbate the effects of HIV, while they bolster gender inequality. In response, strategies to address HIV
must anticipate and address womens and girls complex social, legal and physical vulnerabilities to HIV
and strengthen their human rights and access to justice, through multisectoral approaches to achieve
the Millennium Declaration and Development Goals (Jewkes, Dunkle, Nduna, & Shai, 2010) (UNAIDS, 2010).
2.2 International legal frameworks for women, girls and HIV
International and regional norms and standards can serve as an effective framework for guidance in developing law addressing the intersections of HIV and gender. The Millennium Development Goals (MDGs)
provide a framework for addressing inequality and HIV, emphasizing the importance of building linkages
between HIV, sexual and reproductive health and rights policies, programmes and services, and efforts to
end violence and discrimination against women and girls (Moodley, Pattinson, Baxter, Sibeko, & Abdool
Karim, 2011). Millennium Development Goal 2 promotes gender equality and the empowerment of women.
MDG 6 calls for the halting or sustainably reversing HIV by 2015 and MDG 5 is to improve maternal health
and reduce maternal mortality, including reducing HIV infection and its impacts.
International and regional commitments on HIV and human rights include the United Nations General
Assembly Special Session on AIDS Declaration of Commitment (2001) and the Political Declaration on HIV/
AIDS (2006) and (2011), and the Convention on the Elimination against All Forms of Discrimination against
Women (1979). Policy commitments such as the Cairo Programme of Action from the International Conference on Population and Development (1994) and the Beijing Declaration and Platform for Action from
the Fourth World Conference on Women (1995) also provide important guidance. 3
Regional commitments in eastern and southern Africa contain strong affirmation of womens human
rights generally as well as some specific attention to womens sexual and reproductive health and rights.
For example, the African Unions Maputo Declaration on HIV/AIDS, Tuberculosis, Malaria and other Related
Infectious Diseases (2003) notes that the majority of those infected with and affected by HIV/AIDS in our
continent are women, children and young people and the disproportionate burden of care that falls on
women and it commits to taking action in conformity with the principles of equal access and gender
equity (African Union, 2010). The groundbreaking Protocol of the African Charter on Human and Peoples
Rights on the Rights of Women in Africa (known as the African Womens Protocol, adopted in 2005) recalls
commitments to the principle of non-discrimination and it heralds equality and non-discrimination as
central priorities for HIV prevention and mitigation. It calls for, inter alia: eliminating discrimination against
women; upholding the right to health of women, including sexual and reproductive health; the right to
choose any method of contraception; the right to self-protection and to be protected against sexually
transmitted infections, including HIV; and the right to be informed on ones health status and on the
health status of ones partner, particularly if affected with sexually transmitted infections, including HIV, in
accordance with internationally recognized standards and best practices.
3. There have been several international meetings of heads of state and other leaders who have reaffirmed their commitment to stopping the spread and mitigating the
impacts of HIV. Both the Fourth World Conference on Women held in Beijing and the five year review (Beijing+5) brought together government representatives who
agreed on the importance of integrating a gender perspective into the HIV/AIDS response. The Convention on the Elimination of all Forms of Discrimination against Women
(CEDAW) committed governments to take appropriate measures to eliminate discrimination against women in the field of health care. The CEDAW Committee has also
released a General Recommendation on HIV/AIDS to guide implementation of appropriate measures.
15
The SADC Protocol on Gender and Development (SADC, 2008) contains a section devoted to womens
health and HIV/AIDS, with Article 27 focusing specifically on the unequal status of women and girls, addressing harmful practices, developing gender-sensitive strategies, ensuring universal access to treatment
for women, men, girls and boys, and tackling the disproportionate burden of care placed on women.4
The commitments embodied in these declarations, and in the full range of human rights norms and
standards, offer legal standards and policy recommendations to help local, national and international
leaders address the epidemic in integrated, effective, and gender-transformative ways (UNDP, 2010). They
emphasize that a rights-based approach requires equal access to prevention, treatment, care and support
for those at risk of, living with, and/or affected by HIV. A large number of countries in ESA have committed
to these and other key human rights treaties, and are obligated to implement their provisions at a national
level (Gerntholtz & Grant, 2010).
2.3 Key challenges and ways to address them
When it comes to issues of gender and the law, it is always useful to begin by distinguishing between
what the laws says (de jure) and how the law is practiced (de facto). In the context of gender, the law and
HIV, this contrast is brought into sharp focus, particularly with the interactions between statutory law and
customary law within the context of diverse cultures and traditions. In 2007, the UN Special Rapporteur
on Violence Against Women commented that:
Culture can be defined as the set of shared spiritual, material, intellectual and emotional features
of human experience that is created and constructed within social praxis. As such, culture is
intimately connected with the diverse ways in which social groups produce their daily existence
economically, socially and politically. It therefore embraces both the commonly held meanings
that allow for the continuation of everyday practices as well as the competing meanings that
galvanize change over time. (Erturk, 2007)
Negative traditional social and cultural norms reinforce and are reinforced by discriminatory practices.
Even when the law upholds womens rights, customary laws and practices often work against women
and keep them from fully realizing their rights, such as traditions that encourage early marriage or limit
or deny property rights and inheritance. The potential for this negative spiral points to the importance of
connecting law, gender and HIV.
Legal empowerment for women and girls (as well as for men who have sex with men and transgender
persons) requires a range of laws and policies that ensures that their rights are respected, protected and
fulfilled. In the context of HIV, an enabling legal environment must adequately increase access to justice
as well as to prevention, treatment, care and support (UNDP, 2010).
There are increasingly successful efforts to work with traditional leaders in eastern and southern Africa
to strengthen the rights of women and girls. For example, the cultural structures project of the Kenya
Ethical and Legal Issues Network on HIV and AIDS (KELIN) has been working with elders in five districts to
intervene in cases where widows and orphans have been denied their rights to access and inherit family
land after the death of their husbands and fathers (see Box 2.1 below).
4. You can also find commentary at http://www.africafiles.org/article.asp?id=18881
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Box 2.1 Working with cultural structures to facilitate access to justice to

women and children: a case study from Kenya
Disinheritance of property from widows and orphans has become one of the acute problems in light of HIV. Often, this
takes place in the name of culture and tradition. In addition, access to the formal legal system is difficult, lengthy and
expensive. When dispossessed of their property in rural communities, many women and orphans are forced to move
to urban areas where they often find their vulnerability to HIV increased.
In response, KELIN has successfully formulated a culturally appropriate legal solution to uphold womens inheritance
rights through a series of community dialogue forums and human rights training programmes. By harnessing
customary legal systems in five districts, the Cultural Structures Project has succeeded in securing property and
inheritance rights for widowed women in 49 cases. A further 40 cases are still ongoing.
In some instances, the widows won their cases before the community courts and were awarded land, and yet they
lacked resources to build a home for themselves. KELIN facilitated the construction of 11 semi-permanent houses for
many of these vulnerable widows, using the construction process as a way of bringing the community together and
involving them in the reparation process, as the community provided free labour.
Through this process, fulfilment of the womens social right to housing has created conditions for fulfilment of their
civil and political rights to gender equality, security of the person and access to justice. The success of this approach
has created an increasing demand in other communities to address other cultural practices that expose women and
girls to a higher risk of HIV infection. This approach is now recognized at Article 159(c) of the Kenyan Constitution.
Source: Allan Maleche, KENLINK; www.kelinkenya.org
2.3.1 Compromised social and economic rights, including land and property
Efforts to address the structural determinants of HIV have not yet received adequate attention, particularly
from the perspective of developing enabling legal and policy environments. Women who own property
and have access to other economic assets are generally less vulnerable to HIV and violence and they are in
a stronger position to deal with the impacts of HIV (Ashenafi & Tadesse, 2005) (Strickland, 2004). However,
even in countries where laws promote human rights, many women are still unable to protect themselves
against disenfranchisement, owing to mens legal or community-sanctioned control of household decisions and resources, often articulated in legal terms, whereby women may be considered legal minors
(UNDP, 2010). Unequal or insecure property and inheritance rights create negative consequences for
women, regardless of HIV status. However, when combined with the social stigma and discrimination
against women and girls living with HIV, this can result in extreme, sometimes fatal social and economic
deprivation. For example, women may face violence or eviction from their homes after the disclosure of
serostatus (Combrinck & Wakefield, 2008). They may be evicted from their homes upon death of their
husbands, particularly when the death is due to AIDS and they may be subject to violence in the form of
widow cleansing.5
In Namibia, for example, according to the Legal Assistance Centre (Legal Assistance Centre, 2011), the
bottom line is that there are hardly any economically productive assets that devolve to women, as they
only access these items through their fathers, sons, brothers, etc. It is very clear that men own the property
and women only have the usufructs.6 Women who lack legal protection and equal rights to inheritance
and property experience significantly greater economic insecurity and dependency on male relatives.
This insecurity can lead women to stay in abusive relationships or turn to high risk behaviours such as
exchanging sex for food, shelter and other basic necessities. Far too often, womens economic insecurity
results from laws that overtly discriminate against women or have the effect of discriminating against
women. This is intensified by customary laws that disadvantage women and privilege mens ownership
and decision-making capacity over land and property.
However, while unequal access to land and inheritance presents obstacles to all women, especially to
women living with and affected by HIV, there are also increasing examples of good practice in this area.
In Ethiopia, women are often taught that inheritance is a family matter and that they may face serious
penalties when they assert their rights (PlusNews, 2007). In response, the United Nations Development
Programme (UNDP) and UN Women conducted a joint initiative to address the underlying gender in5. For example, see (Swaminathan, Walker, & (eds), 2008). Another report by the Human Rights Watch documents property rights violations against women in Kenya. This
report notes womens property rights violations are not only discriminatory, they may prove fatal. The deadly HIV/AIDS epidemic magnifies the devastation of womens
property violations in Kenya, where approx. Fifteen per cent of the population between the ages of 15 and 49 is infected with HIV. The report documents how the
intersection between social stigma and discrimination against women and girls living with HIV and womens lack of property and inheritance rights can result in extreme,
sometimes fatal, social and economic deprivation (Human Rights Watch, 2003).
6. Usufruct can be defined as the legal right of using and enjoying the fruits or profits of something belonging to another (see http://www.merriam-webster.com/
dictionary/usufruct).
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equalities that promote inequitable access to inheritance and property, through which they built the
capacity of over 60 community leaders (UNDP, 2009). Workshop participants quickly took initiative in addressing womens inheritance and property rights. Specific actions included: the training of legal experts
(judges, prosecutors and law enforcement officers) on the provisions available to women to inherit and
own property and measures they can adapt to uphold these laws; the use of public campaigns and radio
programmes to improve awareness and knowledge, specifically through interviews of women affected
by these issues, supplemented with basic legal information on womens inheritance and property rights;
and translation and dissemination of legal provisions into the local language (Berg, Horan, & Patel, 2009).
In Rwanda, the Forum Against the AIDS Scourge (FAAS) provides legal services for women survivors of
violence and women victims of property rights violations, as part of its HIV response. The initiative has
improved legal services for women and, at the same time, trained judges, prosecutors, judicial police and
advocates on the rights of people living with HIV. Indeed, Rwandas Permanent Secretary in the Ministry
of Justice, Esperance Nyirasafari, hailed FAAS for its innovative approach to improving the rights of the
people living with HIV (Ndol, 2010).
2.3.2 Inequality entrenched in family law
Failures in the family law context exacerbate links between HIV and gender. Violations of womens rights
with respect to family include, but are not limited to, inheritance rights, custody rights, marital rape and
freedom of movement. Changes to family law overlap with reforms in social and economic rights, particularly in inheritance laws that allow property to pass through the firstborn male only. The combination
of gender inequality and HIV-related stigma can leave a woman widowed by the death of her husband to
AIDS without access to the property that was very much a part of their marital unit. Law may deny women
custody of children upon divorce or on account of their HIV-positive status.
This is aggravated when women living with HIV lose support of their family and community as a result of
stigma. While women are often blamed for bringing HIV into the home (Paoli, Manongi, & Klepp, 2004),
more than 80 per cent of new HIV infections in women result from sex with a husband or primary partner
(UNFPA, 2005). Irrespective of this fact, in many countries women still have unequal rights in marriage and
with respect to the contract of marriage itself and may even be denied legal protection against rape by
their husband or male partner. Even where statutory laws protect women, when family law is grounded in
negative aspects of religious or customary law, the contradiction with statutory law often leaves women
with little access to justice.
Traditionally, human rights law addresses only the actions of state actors and, therefore, violations in the
private sphere and within a family are not normally addressed by it (Romany, 1993). The sphere of privacy
surrounding family life from government intrusion is used as a rationale for abstaining from applying human rights law to violations of rights within the family (Romany, 1993, pp. 102, 105). This artificial distinction
results in insufficient attention being paid to family law and is intertwined with the continuing reliance
on both statutory and customary law, where a states reluctance to govern in areas traditionally seen as
private, leaving those areas of law to customary legal systems, leaves women within those minority communities vulnerable to discrimination. (Bond, 2010) (Coomaraswamy, 2002) (ICHRP, 2009).7
Womens rights organizations have challenged this sphere of privacy, particularly in the context of customary law. For example, the Kenyan National Human Rights Commission has facilitated meetings between
Luo widows who were denied inheritance of the land from their in-laws and community authorities. The
Commission created a framework in which widowed women are encouraged to articulate their predicaments, while the elders defend the principle that the Luo culture protects women. Challenged this way,
the elders started to help women obtain land titles from families denying their inheritance (Chopra, 2007).
Work by the Legal Assistance Centre in Namibia also demonstrates progress in greater recognition of
womens rights especially in the context of HIV by traditional authorities.8
7. For a more general overview, see (Economic Commission for Africa, 2005)
8. For more information, go to http://www.lac.org.na
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2.3.3 Punitive laws and policies
Punitive laws and policies can increase womens risks to HIV and vulnerability to HIV-related rights violations. Laws seeking to criminalize a range of behaviours that have been associated with HIV transmission
often have gender-specific negative effects. Some laws inadvertently hamper national HIV responses,
for example, laws that prohibit sex work and same-sex sexual behaviour and laws that impede harm reduction. These impacts make key vulnerable populations fearful and reluctant to access HIV prevention,
treatment and care services (UNDP, 2010). In ESA, almost all HIV-specific laws criminalize HIV transmission
or exposure, most legal systems criminalize aspects of sex work, and criminalization of same-sex practices
is widespread (UNAIDS, July 2010).
Criminalization of HIV transmission can be particularly burdensome for women. Applying criminal law to
HIV exposure or transmission does little to address gender-based violence or the deep economic, social,
and political inequalities that are at the root of womens and girls vulnerability to HIV and is likely to be
counterproductive (Athena Network, 2010). Laws in Kenya, Rwanda and Zimbabwe, for example, allow
prosecution of women who have transmitted HIV to their children in utero for intentional transmission of
HIV. Such legal action tends to deter testing and discourages women from seeking proper antenatal care
and HIV testing. As one analysis notes:
PMTCT programs should be a place of safety and security for HIV-positive women who are
pregnant and giving birth. Instead many have become a site of human rights violations.
Criminalization of HIV transmission from mother-to-child exacerbates the current stigmatization,
neglect, and violence that occur in hospital settings against HIV-positive women. In turn,
criminalization serves to make PMTCT programs less effective in their goal of preventing
transmission of HIV. (Ahmed, 2011)
2.3.4 Violations of the right to bodily integrity
Women in many countries lack the ability to protect themselves from practices that are psychologically
and physically harmful, and/or conducted in the name of culture or religion, such as genital cutting, dry
sex or date rape. Laws providing unequal protection to women intensify the impact of these practices.
Women who are living with or affected by HIV are further constrained from protecting themselves from
HIV-related stigma and discrimination and from preventing violation of their bodily integrity.
With respect to health care, women living with HIV face further legal obstacles as a result of laws that
explicitly discriminate against women and can even constitute serious violations of womens reproductive
rights, including coerced and forced sterilization or abortion (International Community of Women Living
with HIV/AIDS, 2009). When combined with other forms of marginalization, women living with HIV may
face enormous obstacles gaining access to justice, as well as to affordable, accessible, acceptable and
quality health care and services.
Many HIV laws and proposed laws in ESA require disclosure of HIV status to a partner, without corresponding actions to protect women from violence upon disclosure. In the context of rape, few countries
have developed and implemented comprehensive post-rape care protocols that include post-exposure
prophylaxis and accessible legal and psychosocial support. Such failures in the law abrogate rights guaranteed by national constitutions and make it difficult for women living with HIV to trust the health care
systems in their countries.
2.3.5 Unenforced laws and lack of due diligence
Where countries do have adequate laws, the laws may not be enforced. Many countries have laws that
are protective of womens rights and provide for equal access. However, even in places with progressive
laws, these laws often exist only on the books but not in practice. Moreover, women face a plethora of
obstacles when trying to access the legal system, including lack of awareness of laws that protect their
rights, high travel costs to and from city centres, expensive court fees, inadequate representation and
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limited availability of informal court procedures. Many governments do not exercise due diligence, i.e.
they do not take all possible measures to respect, protect and fulfil the human rights of women and girls
or other key populations at higher risk of HIV.
In other cases, laws that are protective for women living with HIV are compromised because of contradictory practices. When there are conflicts between statutory, customary and religious law and/or practices that
are harmful to womens and girls health and rights, legal protection against discrimination and violence is
weakened. For example, where statutory law grants equal citizenship rights to all, but customary practice
denies women full adult citizenship, rights can be curtailed and vulnerability to HIV may be heightened.
In Rwanda, for example, despite broad moves to guarantee equality between women and men, the civil
code stipulates that the husband is the head of the household (Article 206, 1988).
Protective laws may not be followed up with corresponding policy to translate the law into processes for
the administration of justice for example training police, judges, lawyer and prosecutors to promote
and implement laws and policies that prohibit gender-based discrimination and discrimination against
people living with HIV.
In response, organizations addressing gender inequality and HIV are looking to successful initiatives to
engage informal justice mechanisms. For example, the Federation of Women Lawyers-Kenya coordinates
and supports NGOs to ensure that alternative dispute resolution processes proactively address gender
equality issues in the country. The Coalition to End Violence Against Women (COVAW) conducted a study
in Nairobi province, examining the responses of various institutions to the needs of women and children
affected by violence. The study found that chiefs and assistant chiefs handle more reports of domestic
violence than do the police. In addition, assistant chiefs are responsible for most cases of spousal neglect,
adultery, child custody, and separation, all of which have far-reaching implications for gender relations.
(COVAW, 2002)
Zambias Women for Change (WfC) has been awarded for its work with traditional leaders to address
gender equality and HIV issues, and has helped support a regional SADC initiative in building awareness
and capacity among traditional leaders. WfC conducts workshops for village chiefs and headpersons on
gender, human rights and HIV. In reporting progress and challenges for 2010, WfC noted that, where community workshops had taken place, positive changes had also taken place. This included an increase in
awareness of HIV and AIDS and human rights, confirmed by the increase in the number of human rights
abuse cases being reported. In some cases negative cultural practices that render women more vulnerable to HIV had been banned, such as sexual cleansing, spouse inheritance and early marriage (WfC, 2009).
2.4 Guiding principles for future action
Human rights-based legislation and strategies that foster freedom from discrimination and violence and
promote access to justice can help women and other key populations overcome cultural, social and
political barriers and discriminatory practices. For example, the law can be designed to protect womens
rights to freedom from violence and coercion, as well as to safeguard autonomous sexuality and sexual
diversity (Cook, 1999). It can also promote equality in marriage and access to resources such as property
rights upon divorce or the death of a spouse, often due to AIDS. It can protect the right to privacy during
testing and counselling as well as to health and legal services. For all of these reasons, enabling legislation, combined with affordable and accessible legal services, is critical to preventing, responding to and
mitigating the impacts of HIV (UNDP, 2010).
Specific strategies are essential in each particular context. Certain general principles can help guide a
comprehensive evaluation of the interactions of the law with respect to gender and HIV. Some of these
follow directly from the discussion above: securing womens economic, social and cultural rights along
with their civil and political rights; reforming family law from the perspective of gender equality; repealing
and reforming punitive laws and policies; and ensuring womens rights and the rights of key populations to bodily integrity.
Several other principles will help lead toward good and effective practices addressing the issues. These are:
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2.4.1 Increasing womens access to justice and participation in decision-making
A comprehensive HIV response addresses womens economic, social, and cultural inequalities as well as
securing their civil and political rights through just laws, a strong legal system and a transparent system
for the administration of justice. It must do so through the participation of women and people living with
and affected by HIV and AIDS, specifically sex workers, women and girls from racial and ethnic minorities,
indigenous women and girls, domestic and migrant workers, women in conflict settings, women and girls
living with HIV, lesbians, women in prison, drug users, and other vulnerable women and girls.
Increasing the participation of women in all forms of decision-making, from parliaments to local government, private enterprise, civil society organizations, emergencies and peace-making fora, will ensure
that more attention is paid to meeting the needs of women and girls in the context of HIV. Principles of
rights-based programming, for example participation, transparency and accountability, will also be central
elements of effective and rights-based responses.
2.4.2 Addressing harmful gender norms and engaging men and boys as partners for gender
equality
Involving men and boys in gender equality is different from the status quo in which men are in charge.
In order to be gender-transformative, programmes need to encourage men and boys to work alongside
women and support them in achieving their goals. Building solidarity between men and women toward
gender equality and poverty alleviation will be instrumental in curbing the HIV epidemic and ensuring
sustainability.
National AIDS plans, policies and programmes should be informed by robust gender and vulnerability
analyses to understand how gender norms and power structures leave specific groups of women and men
more vulnerable to HIV, including an examination of how social constructions of masculinities contribute
to HIV. National responses should prioritize gender-transformative strategies, support male involvement
in HIV programming, and increase the uptake of HIV prevention, treatment and care services among men.
Gender-transformative programming that has shown evidence of effectiveness should scale up and disseminate results and learning. Partnerships should be strengthened between national AIDS programmes
and civil society groups working with men, including non-heterosexual men, to ensure that action to
engage men in HIV responses also empowers women and girls; and to promote joint prevention programming that engages women, men, girls and boys.
2.4.3 Engaging formal and informal mechanisms to secure womens rights
Ensuring womens rights and accelerating action to address the gender dimensions of HIV requires a focus
on both formal and informal legal mechanisms. This means utilizing (gender transformative and equity)
laws that are available but lack implementation, and strengthening legal practice through training, strategic
litigation and policy reform. The strategic litigation of cases that violate the constitution or national laws
can effectively promote and protect the rights of women living with HIV (Ofosu-Amaah, 2004). Customary
and traditional structures should also be harnessed to support gender equity and transformative strategies. Many women may choose customary or alternative dispute resolution mechanisms, such as arbitration and mediation, as they are faster, less expensive and more accessible than formal court processes.
If due attention is paid to womens empowerment, these mechanisms can help to promote and protect
womens rights.
2.4.4 Ensuring rights and opportunities in the workplace
The HIV epidemic has a significant impact on the labour force as it can reduce earnings, skills and experience for employees, while increasing labour costs and reducing productivity for employers. The HIV
epidemic drastically affects the age and gender distribution of the labour force as people in their prime
productive years of between 15 and 49 are often the most likely to be living with HIV. This also increases
the number of widows, orphans and elderly people who face greater economic insecurity and greater
responsibility for taking care of grandchildren and/or ill parents. HIV can also pose a threat to employees
rights in the workplace as there is widespread discrimination and stigmatization of those living with or
affected by HIV.
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The International Labour Organization (ILO)s Code of Practice on HIV and the World of Work (ILO, 2001) promotes gender equality and provides guidance for formulating and implementing workplace policies that
address discrimination. The Code also covers policies and programmes for prevention and care in both
the formal and informal sectors. This is particularly important since women in ESA are concentrated in
the informal economy.
2.5 Recommendations
Box 2.2 below provides a summary of key actions to reduce stigma and increase access to justice in national HIV responses.
Box 2.2 Key actions to reduce stigma and discrimination and increase access to
justice in national HIV responses
1. Stigma and discrimination reduction
2. HIV-related legal services
3. Monitoring and reforming laws, regulations and policies relating to HIV
4. Legal literacy (know your rights)
5. Sensitization of law makers and law enforcement agents
6. Training for health care providers on human rights and medical ethics related to HIV
7. Reducing harmful gender norms and violence against women and increasing their legal, social and economic
empowerment in the context of HIV
Source: UNAIDS 2010
Eight key recommendations are given here to strengthen national HIV responses through legal mechanisms that support gender equity and the rights of women, men and children.
2.5.1 Land and property rights
Creating a legal environment that secures womens social and economic rights is of paramount importance in HIV responses. For instance, women with access to property rights and land ownership are less
vulnerable to violence and HIV. Research in Kerala, India, suggests that 49 per cent of women without
property reported physical violence, as opposed to only seven per cent of those who did own property.
(Knox, et al., 2007) Enabling inheritance and property rights places women in a stronger position to make
decisions surrounding HIV affecting their lives and the lives of their family members for whom they are
charged with caring.
2.5.2 Reforming family law
Reforming family law should be included as a part of a comprehensive HIV response. It is also imperative
for community and religious leaders to be sensitized to the needs of people living with HIV as well as
womens rights in order to bring about family law reform. Effective reform of family law also requires a
re-evaluation of the public-private distinction facilitated by a formalistic application of human rights law.
2.5.3 Rejecting punitive laws and policies
Laws that criminalize HIV exposure, sex work, same-sex practices and harm reduction are increasingly
being viewed as hampering the AIDS response and can have particularly negative impacts on women
(UNAIDS, 2010). Such laws should be reviewed and revised in line with evidence on how the promotion
and protection of human rights is an important component of effective AIDS responses. Simultaneously,
laws that discriminate against women, including where customary and statutory law conflict, should be
brought in line with international and regional human rights norms and standards, especially the Convention on the Elimination of All Forms of Discrimination against Women and the African Womens Protocol.
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2.5.4 Protecting the right to bodily integrity
Women often lack protection for their bodily integrity, especially in contexts where sexual assault and
marital rape are not considered to be criminal acts. In countries where legislation is discriminatory or
absent, efforts should be focused on law reform. Such steps can be combined with national efforts to
design and implement comprehensive post-rape care protocols that include post-exposure prophylaxis
and emergency contraception. For example, South Africas Domestic Violence Act allows women in various
forms of domestic partnerships, not only those who are married, to access quick and affordable protection
orders as protection from a wide range of domestic violence (Domestic Violence Act 116, 1998).
2.5.5 Prevention of mother-to-child (vertical) transmission
With respect to preventing vertical transmission, this must be achieved within the framework of promoting
and protecting the human rights of women, integrating HIV and sexual and reproductive health care, and
ensuring a commitment to womens health throughout their life cycles and not only during pregnancy.
The new Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping their
Mother Alive (UNAIDS, 2011) provides specific recommendations for action that encompass womens health
and human rights as well as the rights of children.
2.5.6 Eliminating gender-based violence
A growing number of strategies provide good practice for addressing gender-based violence and especially violence against women and girls in the context of HIV. For example, Stepping Stones provides
training packages for addressing gender and HIV together, across all regions, based on the principle of
engaging families and communities to challenges harmful gender norms and gender-based violence.9
Good practice also stresses the importance of working with families and communities, while providing
designated space to help support womens capacity building and awareness raising.10
2.5.7 Strengthening legal literacy
In some situations, women might be unaware of the existence of laws protecting them from discrimination
and violence. In such contexts, it is of utmost importance that HIV programming link with legal services
to provide accessible and affordable services and support to women living with HIV, as well as translating
laws into basic terminology and local language to increase accessibility and availability of legal services.
Programming can be designed to strengthen womens and girls access to justice and empower women
to exercise their rights, including by ensuring their informed consent and enhancing legal literacy.
2.5.8 Implementing unenforced laws
On a national level, institutional capacity and governance mechanisms should be strengthened in order
to enforce and implement the international human rights commitments governments have signed. For
example law enforcement officials, police, legal professionals and members of the judiciary need to be
sensitized about the legal dimensions of HIV and its impact on women. Furthermore, law enforcement
officials should be educated about relevant laws and sensitized to ensure that their enforcement brings
perpetrators of human rights abuses to justice and provide redress for survivors.
9. See http://www.steppingstonesfeedback.org.
10. For example, Raising Voices SASA! Project is currently being rolled out in Uganda and Tanzania. It provides practical materials
and information to organizations to integrate into their existing HIV and VAW programmes to address GBV and HIV in tandem
and recognize the linkages between the two. In addition to its Kiswahili meaning, SASA! is an acronym for the four sections of
the Activist Kit: Start, how to begin your work; Awareness, educating and providing information on the link; Support, providing
suggestions and a platform for discussion on how we can create supportive relationships and communities; Action, practical
ideas for how everyone can prevent VAW and HIV. For more on SASA!, see: www.raisingvoices.org/files/SasaCaseStudy.nov07.pdf.
23
2.6 Conclusion
In moving forward, the guiding principles we have listed above can help support efforts to grapple with
the intersection of gender, HIV and the law. Equally importantly, a comprehensive response will reach beyond the public sphere alone. Rather, it will include attention to the private sphere (and in this context, the
structures of family law), in which women so commonly experience violations of rights that go unnoticed.
As we noted at the outset of this technical paper, inequality drives and exacerbates the impact of HIV and
results in inequitable impact on those who are the most legally disempowered. In turn, these fuel gender
inequality, violence and other forms of discrimination and ill-treatment. Addressing the structural drivers of
HIV and gender inequality can have a profound impact, both on the epidemiology of HIV and on progress
towards achieving long-term development, health and human rights goals. National HIV responses must
be reoriented to support womens legal rights, as well as gender equality, inside and outside the home,
protect women and girls from violence, and change gender norms that put men and women at risk (IPU,
UNAIDS, UNDP, 2007). Women and men must have access to the legal, economic, social, and health opportunities and rights to avoid HIV and to better cope with the impact of the epidemic.
2.7 References
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Athena Network. (2010). 10 Reasons Why Criminalization of HIV Exposure or Transmission Harms Women.
Berg, N., Horan, H., & Patel, D. (2009). Womens Inheritance and Property Rights: A Vehicle to Accelerate Progress towards
the Achievement of the Millennium Development Goals. Rome: IDLO Legal Empowerment Working Papers.
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Chopra, T. (2007). Promoting Womens Rights by Indigenous Means: An Innovative Project in Kenya. In World Bank,
Justice for the Poor. Washington DC: World Bank.
Combrinck, H., & Wakefield, L. (2008). At the Crossroads: Linking Strategic Frameworks to Address Gender-Based Violence
and HIV/AIDS in Southern Africa. Belleville: University of the Western Cape.
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Cook, R. (1999). Womens Health and Human Rights: The Promotion and Protection of Womens Health through
International Human Rights Law. Adapting to Change Core Course.
Coomaraswamy, R. (2002). Identity Within: Cultural Relativism, Minority Rights and the Empowerment of Women.
George Washington International Law Review, 483.
COVAW. (2002). In Pursuit of Justice: A Research Report on Service Providers Response to Cases of Violence Against Women
in Nairobi Province, 2002. Coalition on Violence Against Women.
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Economic Commission for Africa. (2005). Promoting Gender Equality and Womens Empowerment in Africa:
Questioning the Achievements and Confronting the Challenges Ten Years After Beijing.
Erturk, Y. (2007). Report of Yakin Erturk, the UN Special Rapporteur on Violence Against Women, Its Causes and
Consequences, Intersections between culture and violence against women. New York: United Nations.
Gerntholtz, L., & Grant, C. (2010). International, African and country legal obligations on womens equality in relation to
sexual and reproductive health, including HIV and AIDS. Durban: HEARD and ARASA.
Gupta, G. R. (2000). Gender, sexuality, and HIV/AIDS:the what, the why, and the how. Canadian HIV/AIDS Policy Law
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24
Gupta, G., Parkhurst, J., Ogden, J., Aggleton, P., & Mahal, A. (2008, August). Structural approaches to HIV prevention.
The Lancet, 372 (9640), pp. 76477.
HIVAPCoP web site. (n.d.). E-discussion on the socioeconomic impact of HIV on women and girls in Asia and the Pacific.
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25
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Sexual and reproductive health, gender and HIV
Sexual and reproductive

health, gender and HIV:
post-Maputo progress
made towards universal
access and the MDGs
3.1 Introduction
Although sub-Saharan Africa only has ten per cent of the global population, it
has 60 per cent of the HIV burden and only ten per cent of global health expenditure. Hence the region faces an exceptionally high disease burden while grappling with inadequate access to functional, effective and affordable services.
Due to a combination of biological, social and structural factors, the regions HIV
epidemic disproportionately burdens females; sixty per cent of women living in
the region are HIV-positive. Gender inequality is a key driver of the epidemic in
the region and underlying factors include gender-based violence (GBV), intergenerational sexual relationships and the relative economic disempowerment
of women and girls (SADC, 2004).
Gender inequalities play a critical role not only in sexual reproductive health and
HIV programming, but in the socio-economic development of Africa, according to
the Sixth African Development Forum: It has become widely accepted that promoting
gender equality, womens empowerment and ending violence against women is essential
to achieving human development, poverty eradication and economic growth on the
African continent. (ECA, AU, ADB, 2008)
3.2 International agreements
The vast majority of African countries is party to key international human rights
instruments that protect not only civil and political rights as well as socioeconomic
and cultural rights (including the International Covenant on Economic, Social and
Cultural Rights and the International Covenant on Civil and Political Rights), but also
womens rights, including the 1979 Convention on the Elimination of all forms of
Discrimination Against Women (CEDAW).
Held in Cairo in 1994, the International Conference for Population and Development
(ICPD) re-energized international attention on reproductive health by declaring
universal access to sexual reproductive health and rights (SRHR) as a major development goal (United Nations, 1994). The ICPD goals are also linked to Millennium
Development Goal 1 (eradicate extreme poverty and hunger), MDG 3 (promote
gender equality and empower women), MDG 4 (reduce child mortality), MDG 5
UNICEF/NYHQ2008-0800/Isaac
26
27
(improve maternal health) and MDG 6 (combat HIV/AIDS, malaria and other diseases). The Beijing Platform for Action, agreed at the 1995 UN Fourth World Conference on Women, is a global commitment to
promote gender mainstreaming in all government policies and programmes, with health being one of
12 critical areas of concern.
3.3 African legal instruments
Equality and non-discrimination have been the cornerstones of a number of African legal instruments,
including the Charter of African Union (1963) and the African Charter on Human and Peoples Rights (1981).
In 2001, African Heads of States declared HIV a continental emergency and pledged to allocate at least
15 per cent of their respective countries total budgets to improving the health sector through the Abuja
Declaration (Organisation of African Unity, 2001).
The Protocol to the African Charter on Human and Peoples Rights on Womens Rights (2003) strengthened womens rights protection by specifically addressing issues of sexual and reproductive rights as
well as HIV and AIDS. Article 14 sets out three major components of womens reproductive health rights
(Gerntholtz L, 2011):
1. reproductive and sexual decision making, including the number and spacing of children, contraceptive choice and the right to self-protection from HIV;
2. access to information about HIV and AIDS and reproductive health; and
3. access to reproductive health services, including antenatal services and abortion-related services.
The Solemn Declaration on Gender Equality in Africa (African Union, 2004) re-affirmed the continental position to expand and promote the gender parity principle and to ensure the active promotion and protection of
all human rights for women and girls. Through the Declaration, heads of state and governments committed
themselves to annual reporting on gender goals. However, an independent evaluation report (Musa, 2010)
noted that only 18 out of 53 Member States had submitted progress reports by 2010.
It has become increasingly apparent that the Millennium Development Goals cannot be achieved without
intensifying efforts. For example, a progress review of ten years of implementation since ICPD noted that
only eight countries had made significant progress, seven countries made moderate progress, and five
made little or no progress (African Union, 2005). Recognizing that the Millennium Development Goals
could not be attained without significant improvement in the SRH service availability in Africa, the Maputo
Plan of Action on Sexual and Reproductive Health and Rights (MPoA) (African Union, 2006) was endorsed
by Health Ministers of AU Member States in 2006.
3.4 The Maputo Plan of Action
The Maputo Plan of Action on Sexual and Reproductive Health and Rights is a harmonized, integrated
action plan based on the respect of human rights. It contextualizes the goals of the ICPD and the MDGs
into a customized, but flexible, framework for member countries. MPoAs overall goal is to ensure that:
African Governments, civil society, the private sector and all development partners join forces and
redouble efforts so that the effective implementation of the continental policy, including universal
access to sexual and reproductive health by 2015 in all countries in Africa, can be achieved.
MPoA aims to realize the ICPD goal of universal access to sexual and reproductive health by renewing
regional government commitments and providing a framework, which countries can use to guide programming by simply incorporating elements into their existing implementation frameworks, rather than
needing to elaborate new ones. MPoAs key strategies include: integrating sexually-transmitted infection
28
(STI), HIV, malaria, and SRH services into primary health care; strengthening SRHR service provision at community level; repositioning family planning as key to the attainment of MDGs; developing and promoting youth-friendly services; ensuring safe motherhood; preventing unsafe abortion; enhancing national
resource mobilization; improving commodity security; and strengthening monitoring and evaluation.
3.5 Review of progress since Maputo
In 2008, the United Nations Population Fund (UNFPA) led a review of sexual and reproductive health and
rights (SRHR) policies, strategies and plans, to assess progress on implementation of MPoA actions at country level (UNFPA, 2009). The review recorded unprecedented actions to revise, develop and update policies,
strategies and plans to reflect global and continental SRHR targets, as highlighted by the Maputo Plan of
Action. Based on data from 35 countries, the review reported that over 40 per cent of them had integrated
HIV, sexually-transmitted infection (STI), sexual and reproductive health (SRH) and malaria services into
primary health care and almost 60 per cent had integrated national SRH strategies. Seven countries had
revised their youth health policies to reflect MPoA outcomes and 15 countries had developed National
Reproductive Health Commodity Security plans.
Although maternal and newborn health was included in most national policies and plans, it remained the
least integrated into other programmes, especially SRHR, youth and adolescent SRH and human resource
national plans.
However, the integration at policy level was not reflected in programme implementation and actual service
delivery, where the significant gap between policy and practice was glaringly evident. Due to a number
of challenges (discussed below) implementation lagged dramatically behind national policies and plans.
However, some progress had been made in increasing access to services using alternative strategies, such
as abolishing user fees and cost-sharing.
The review concluded that, although an enabling policy environment is important and evidence-informed
planning is critical, real progress in newborn, child and womens health can only be made by implementing
effective priority actions, and monitoring them to track progress and adapt implementation to dynamic
contexts, as needed.
Five years after its launch, the African Union also undertook a review of the Maputo Plan of Action, to
document progress and challenges against MPoA outcomes. The main findings are summarized in Table
2.1 below.
29
Table 2.1 Findings from the African Unions review of the Maputo Plan of Action
MPoA Outcome
Finding
Comments/Challenges
HIV, STI, Malaria and SRH

services integrated into
primary health care
Many countries have integrated

service plans in place and some
are already implementing them,
but a few do not yet have the
plans.
The main challenges reported are weak health systems,

including inadequate human resources, unsatisfactory
coordination and the fact that some well-funded programmes
are still vertical and not ready to take on other programmes.
Strengthened communitybased STI/HIV/AIDS and

SRHR services
Many countries have plans in

place and some are already
implementing them.
Communities, including youths and men, should be involved

in all levels of planning and implementation for better results.
Family planning
repositioned as key strategy
for attainment of MDGs
Many countries have supportive

family planning protocols
and guidelines, but need to
implement them more effectively
and to reach all communities in
need. Policies and strategies have
been articulated and adopted in
most countries, but their effective
operation is still a problem.
This requires skilled human resources, social and behaviour

change, communication interventions and community
involvement, as well as regular supplies of commodities. All
of these present challenges. Education institutions, youth and
other groups, and community-based organizations (CBOs) are
important partners in this regard.
Youth-friendly SRHR services

positioned as key strategy
for youth empowerment,
development and
well-being
Nearly two-thirds of countries

reported that they have policies
or strategies in place as well
as centres supporting SRHR
services for young people. Twelve
countries are in the process of
developing them, whilst three
have nothing in place.
Although most countries have policies and strategies in

place, effective operation is still a challenge. Other challenges
include strategies that are not flexible, cultural constraints
and high rates of teenage pregnancies in some countries.
Education institutions, youth and other organizations and
CBOs are important partners in these efforts.
Incidence of unsafe
abortion reduced
Many countries have strategies

in place or are developing
them, although laws and legal
frameworks need review.
Because abortion is generally criminalized, back-street

abortion prevails and post-abortion care is still unsatisfactory.
A strategy for advocacy and education to raise awareness
among youth and to improve the attitudes to abortion of
health workers, teachers and the community at large should
be adopted. The media can play an important role.
Access to quality Safe

Motherhood and child
survival services increased
Road maps for the reduction of

maternal and newborn morbidity
and mortality have been
developed by most countries
(88.4 per cent) and are being
implemented in some.
Providing adequate services including regular supplies

as well as accessing services for emergency obstetric and
neonatal care country-wide still poses a challenge to safe
motherhood and child survival
Resources for SRHR

increased
The available resources are

mainly within the general health
budget, which is limited in some
countries. A few countries do
assign limited but specific budget
lines for SRHR, including family
planning.
Many programmes are donor dependent, which means

that their sustainability is not assured. Local resources
should be mobilized (including from the private sector), and
supplemented by external funds. Staffing shortages are acute,
and generally more acute in rural areas; 14 countries reported
that they had less than 31 midwives per 10 000 people. Staff
shortages are compounded by high turnover, low salaries and
other challenges to do with motivation.
SRH commodity security

strategies for all SRH
components achieved
Although SRHR commodity

security strategies and action
plans are in place, their operation
is still a challenge, sometimes
because of inadequate or delayed
funding. This results in stock-outs
especially in rural areas.
Many countries recommended that reproductive health

commodities be included on the essential medicines list.
Government ownership or the lack thereof is sometimes a
challenge, as external partners support commodity supply in
some countries. The Pharmaceutical Manufacturing Plan for
Africa provides a framework for promoting local or regional
production and should be explored.
Monitoring, evaluation and

coordination mechanism
for the Plan of Action
established
Many countries have

institutionalized monitoring and
evaluation (M&E) systems or are in
the process of doing so.
Competing priorities, inadequate supervision and

coordination, and limited human resources are some of the
challenges countries face in this area. It was recommended
that a Coordination Committee be put in place in the
Ministries of Health if such does not exist. Health information
systems in African countries should be developed and
managed properly for effective M&E and information sharing
and data should be disaggregated by gender and age.
Source: African Union, 2010: Maputo Plan of Action Progress Report
The African Unions review of the Maputo Plan of Action drew attention to the need for comprehensive
integrated implementation of SRH and HIV prevention and the involvement of all stakeholders, including
communities, to address negative social cultural issues and determinants. It also highlighted the significant impact that effective, scaled-up prevention of mother-to-child (PMTCT) programming could have in
reducing the HIV burden in the region. The AU review led to the AU Summit on Maternal Infant and Child
Health, held in July 2010.
30
3.5.1 Remaining Challenges
The AU review summed up typical challenges to full, effective implementation of the MPoA as reported
by Member States:
The main challenges and lessons as highlighted by almost all countries under each priority area
relate to inadequate resources, weak health systems, inequities in access, weak multisector[al]
response, low priority accorded to health in national development plans, and inadequate data.
Insufficient action has been undertaken in a number of key areas, which will impede achievement of key
SRHR commitments, including the MDGs, unless accelerated, intensive, evidence-informed programming
is rolled out in a timely manner. These areas include:
3.5.1.1 Gender equality and rights
More needs to be done to mainstream gender and human rights into national strategies, documents and
programming. One underlying reason is the shortage of robust gender analysis and gender-disaggregated
data in national reporting, and this must be improved using best practice models. The social and economic disempowerment of women and girls continues to limit their access to knowledge, information
and services. This is not adequately addressed in most countries. The many barriers to the promotion and
protection of womens reproductive rights in Africa undermine womens ability to take control of their
sexual health, fertility, autonomy and participation in social and economic life. Womens and childrens
rights need to be supported and mainstreamed into educational, economic and legal policies. Governments have not yet adopted breakthrough measures to address gender-based challenges and improve
progress towards MDG 3.
3.5.1.2 Moving from emergency planning to an integrated response
Strong integration of HIV and SRH requires other broader structural issues to be addressed, such as education, gender and socio-economic aspects. Critical specific areas are age of consent for SRH and HIV
services, gender-based violence, child marriage, sexuality education and the meaningful participation of
key populations such as young people, men who have sex with men, women etc (UNAIDS, 2010). However,
these linkages are challenged by historical facts that demanded an emergency response at the outset of
the HIV pandemic, as well as the fact that the initial HIV clients were different from traditional SRH ones.
These challenges were enhanced by vertical and earmarked donor funding, the creation of independent
HIV units outside of SRH departments and the paradigm that HIV prevention and treatment should be
delivered separately as well as the exceptional view that HIV is specialized and requires specialized training
and skills outside and well above those in SRH. This counterproductive approach has not only aggravated
stigma and discrimination, but has also failed to provide integrated responses to common issues related
to HIV and sexual and reproductive health for men and women.
3.5.1.3 SRHR for all ages
If the goals of the Maputo Plan of Action are to succeed and attain universal access to sexual and reproductive health and rights, especially for women and girls, it is critical that reproductive health is seen to
encompass the whole life span of an individual from conception to old age and that appropriate SRH
services be provided to all who need them, regardless of age. Special emphasis should be placed on men
and women of reproductive age, newborns, young people, rural, mobile, and cross-border populations,
displaced persons and other vulnerable and marginalized groups, focusing on where the greatest impact
can be achieved.
3.5.1.4 Limited resources
In an era of diminishing funds for sexual and reproductive health programming, including HIV responses, it
is increasingly critical that African countries show leadership by meeting their commitment of allocating 15
per cent of national budgets towards health services. Botswana has led the way by being the first country
to attain and surpass the 15 per cent allocation of the national budget to the health sector (African
Union, 2010). Other countries have developed innovative mechanisms to increase domestic resources for
sexual and reproductive health and rights, such as Zimbabwes National HIV and AIDS Levy, which is a
three per cent levy on income tax.
31
3.5.1.5 Insufficient availability of robust operational evidence
Although it is often overlooked in budgeting and planning, substantive operational research is needed
to guide evidence-informed policy-making and programming. Monitoring and evaluation frameworks
need to be strengthened, to collect sufficiently disaggregated and standardized data and to ensure that
evidence can be compared across programmes and used to attribute impact as well as process.
3.5.1.6 Ensuring community ownership
The success of SRH programmes may depend on community ownership and local leadership as well as
bottom-up planning, making community involvement a pillar of effective implementation. In this regard,
men's and boys involvement is critical, as shown by recent studies (World Health Organization, 2007).
3.6 Recommendations
The main recommendation to come out of the MPoA reviews was to extend the implementation timeframe until 2015, in line with the Millennium Development Goals. This was achieved through a decision of
the Executive Council on the African Union on 15 May 2010. Other recommendations included developing
human resource capacity, bolstering financial resources, improving the quality of strategic information
generation and management, and strengthening linkages to other development mechanisms to address
underlying causes of vulnerabilities.
The following recommendations address some key gaps identified in the post-Maputo reviews:
3.6.1 Strengthening the rights-based approach and accountability
All stakeholders should bear responsibility and call for increased accountability in measuring progress
towards gender-sensitive measures and filling identified gaps. This will require a strong role for civil society,
parliamentarians and others to:
1. take ownership of key documents such as the Maputo Plan of Action and the Abuja Declaration,
linking them to relevant human rights instruments and popularizing them among stakeholders in
their respective areas/countries; and
2. hold executive bodies responsible and accountable for progress and regularly review and report on
performance.
3.6.2 Align national legislation with international commitments
Steps to achieve this include accelerating the ratification and domestication of the provisions contained in
key continental agreements namely the Protocol to the African Charter on Human and Peoples Rights
on the Rights of Women in Africa that address specific challenges on women and sexual reproductive
rights and HIV.
3.6.3 Enhance regional and international cooperation
Coordination among all players must be strengthened in order avoid duplication, increase cost efficiency
by effectively utilising the comparative advantages of various stakeholders, and adopt streamlined frameworks for monitoring, evaluation and reporting.
3.7 Conclusion
Several African countries have embarked on the provision of universal access services, with some measure of success. Since endorsing MPoA, national policy and implementation frameworks are increasingly
prioritizing actions to improve maternal, newborn and child health outcomes, including those that address HIV prevention, treatment and care. However, gender, SRH and HIV challenges faced by women and
girls in sub-Saharan Africa still remain significant and, in order to achieve the effective implementation of
32
MPoA and the attainment of the MDGs, more intense and accelerated action must be taken. In order to
achieve progress at the required magnitude to meet our commitments, strategic, evidence-informed, and
cost effective priority interventions must be implemented at scale, in order to make sustainable, strategic
change in critical sexual and reproductive health and rights areas.
3.8 References
African Union. (2005). Draft Continental Policy Framework on Sexual and Reproductive Health and Rights in Africa. Addis
Ababa: African Union.
African Union. (2006). Maputo Plan of Action for the Operationalization of the Continental Policy Framework for
Sexual and Reproductive Health and Rights 20072010. Addis Ababa: African Union.
African Union. (2010). Maputo Plan of Action Progress Review. Addis Ababa: African Union.
African Union. (2004). Solemn Declaration on Gender Equality in Africa. Addis Ababa: Africa Union.
ECA, AU, ADB. (2008). Achieving gender equality and womens empowerment in Africa Progress Report: The Sixth
African Development Forum (ADF VI). Addis Ababa: Economic Commission for Africa, African Union, African
Development Bank.
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MDGs. PloS Medicine.
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and AIDS Unit.
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programme interventions. Geneva: WHO.
HIV prevention, women, girls and gender equality
HIV prevention, women,

girls and gender equality
4.1 Introduction
Addressing gender norms and inequalities is a fundamental consideration for

effective HIV prevention and progress towards the vision of zero new infections,
zero discrimination and zero AIDS-related deaths (UNAIDS, 2010)1. In sub-Saharan Africa, around 60 per cent of people living with HIV are women, according
to estimates by UNAIDS. In some countries up to six times as many females are
HIV-positive as males in certain age groups among young people aged 15 to 24
(UNAIDS, 2010). A shocking 72 per cent of young people living with HIV in this
region are female (UNICEF, 2011).
Multiple factors have contributed to the severe epidemic in eastern and southern
Africa. Proximate risk factors include low rates of medical male circumcision and
condom use, and a high frequency of multiple and, particularly, concurrent sexual
partners for men and, to a lesser extent, for women. More distal, structural factors
increase the likelihood of concurrent sexual partnerships, notably including high
rates of mobility, separation of long-term partners, urbanization, alcohol use that
is often linked with riskier sex, and socio-economic and gender inequality and inequity. Harmful cultural norms and practices also contribute to HIV transmission in
many countries, such as adolescent sexual initiation rites. Stigma and discrimination
remain fairly widespread, relatively few partners and spouses are likely to openly
discuss sex and sexuality or HIV, and few seek testing and counselling together in
order to act appropriately on the results.
Although most of the region has generalized epidemics and a preponderance of
infection in women and girls, the Indian Ocean Islands have concentrated epidemics driven by a combination of (mainly male) injecting drug users, men who have
sex with men, and sex work, while prison settings also significantly contribute to
new infections.
Notable achievements have been made in prevention over the past decade, with
33 countries, including 22 in eastern and southern Africa (ESA), having reduced
HIV incidence by over 25 per cent from 2001 to 2009 (United Nations SecretaryGeneral, March 2011). Other countries in ESA have seen their epidemics stabilize,
albeit often at high prevalence levels. New infections are only on the rise in a few
generalized epidemics, such as in Mozambique, Kenya and Uganda. HIV incidence
has particularly declined in young people aged 15 to 24, linked with behaviour
change, including delaying sexual debut, increasing condom use and reducing the
number of sexual partners.
There is still a long way to go to achieve the prevention revolution called for by
UNAIDS. The UN Secretary-Generals 2011 Report cites an estimated two new infections for each individual who enters treatment (United Nations Secretary-General,
March 2011). This is definitely progress, but still an unsustainable scenario for the
1. Zero new infections, zero discrimination and zero new deaths have been endorsed as official HIV goals by UNAIDS and in the UN
General Assembly HLM Political Declaration, June 2011
UNICEF/NYHQ2008-0782/Isaac
33
34
future. The burden on women and girls remains excessive and will impact negatively on several Millennium Development Goals (MDGs), notably MDG 3 to promote gender equality and empower women,
MDG 4 to reduce child mortality, MDG 5 to reduce maternal mortality, and MDG 6 to halt and reverse the
spread of HIV and AIDS and ensure universal access to treatment. Progress on these goals is fundamentally
entwined, and the pressing need to achieve them is clearly visible in eastern and southern Africa (ESA),
the epicentre of the HIV epidemic.
Political commitment, financing and programming for HIV prevention over the past few years have generally lagged behind treatment and care, despite countries being signatories to several important declarations and commitments over the past ten to 11 years at global, Africa regional, sub-regional and national
levels. In June 2011, the UN General Assembly High Level Meeting reaffirmed global commitments and
agreed bold targets for 2015 for prevention, treatment and human rights, including particular attention
for women and girls2. These include the commitments already made by the East Africa Community (EAC)
and Southern African Development Community (SADC) to halve the number of new infections by 2015
(from 2009 figures) and for the virtual elimination of mother-to-child HIV transmission (eMTCT).
This paper outlines factors driving vulnerability in women and girls, unpacks challenges for HIV prevention
over the past decade and then addresses strategies to date, making recommendations for the further
responses urgently required to achieve the prevention revolution in this region.
4.2 Factors driving vulnerability in women and girls
Respective male and female risks for HIV infection differ, as do the impacts of the epidemic on women
and mens lives. Males and females have different access to treatment, are impacted differently by stigma
and discrimination and their risks for transmission of infection follow different paths. Gender norms that
perpetuate certain behaviours disempower women and girls, endorse gender inequality and place women
and girls at greater risk. Females face higher physiological susceptibility and vulnerability to infection at an
early age, risk (and are often blamed for) transmitting infection to infants through motherhood and have
socially defined care roles in the family when someone is sick.
For women and girls, many factors associated with lower social, political, legal and economic status than
men, poorer access to education and to remunerative employment, gender and sexual violence, disempowering feminine stereotypes, and socially sanctioned male-concurrent sexual networking contribute to
vulnerability and risk. At the same time, female empowerment is not automatically protective, and there is,
by no means, in the region a consistent correlation between higher education and socio-economic status
for women (or men) and lower prevalence of HIV. Complex factors intervene. Ironically, in several countries
in the region, empowered young urban women have more stereotypically male attitudes to sex and,
thereby, increased risks for HIV by multi-partnering (Leclerc-Madlala, 2009). They are thus at risk from both
their own multiple partners as well as multi-partnering by men. Their empowerment does not extend to
their controlling the conditions of sex, however, such as negotiating condom use to reduce their vulnerability. Many have sexual partnerships with men older than themselves who can provide benefits such
as transport, desired material goods, cash and status, again indicative of the prevailing socio-economic
inequality they continue to face (Leclerc-Madlala, 2009).
Age-disparate sex greatly increases young womens risk for acquiring infection, as older men have higher
HIV prevalence than young men their own age. In turn, HIV-positive young women then infect subsequent partners. Recent Demographic Health Survey data shows young women, overall, reporting fewer
partners and a decline in those reporting sexual relations with partners more than ten years older. These
behavioural changes are contributing to the HIV incidence declines in young women in many countries.
2. Of relevance to HIV prevention and women and girls, global and Africa regional declarations and commitments and high level meetings include: the Millennium
Declaration and Millennium Development Goals, 2000; UN General Assembly Special Session Declaration of Commitment on HIV/AIDS, June 2001, that set universal access
goals for 2010 and was reaffirmed by the June 2006 General Assembly High Level Meetings Political Commitment with strong emphasis on human rights, gender, and the
vulnerability of women and girls; the OAU Abuja Declaration on HIV/AIDS, Tuberculosis and Other Related Infectious Diseases, 2001, and 2006 Abuja Call for Accelerated
Action on HIV/AIDS, TB and Malaria, which upheld previous financial commitments (ahead of the UN General Assembly High Level Meeting, June 2006); 2003 AU Maputo
Declaration on Malaria, HIV/AIDS, Tuberculosis and Other Related Infectious Diseases (ORID) and the 2006 African Union Commission Maputo Plan of Action on Sexual
and Reproductive Health and Rights, 20072010; the 2010 AU Kampala Summit extending the Universal Access commitment to 2015; The Draft Windhoek Declaration on
Women, Girls, Gender Equality and HIV: progress towards Universal Access made at the SADC, EAC and COMESA Meeting in April 2011 that, with multiple other events, fed
into the UN General Assembly High Level Meeting on AIDS, June 2011; the Political Declaration on HIV/AIDS: Intensifying our Efforts to Eliminate HIV/AIDS; Security Council
Resolution 1983 (which links conflict situations to womens vulnerability including sexual violence); and the Global Plan Towards Elimination of New Infections Among
Children by 2015 and Keeping their Mothers Alive.
35
Poverty, of course, can also increase the risk of women selling sex to survive. Urban slums are a particularly
high-risk setting for commercial and casual sex, gender violence and HIV transmission. Urban settings
need to be a major focus for HIV prevention and wider support efforts, within a human rights and gender
framework.
4.3 Barriers to effective prevention
4.3.1 Low investment in HIV prevention
Political commitments notwithstanding, National AIDS Spending Assessments (NASAs) in eastern and
southern Africa tend to show comparatively low spending on prevention, compared with treatment and
care and often poor prioritizing of prevention expenditures. The hidden burden of care that falls on women
and girls in the family is often ignored altogether in costing equations.
Most countries in the region rely heavily on external aid to fund their national prevention (and treatment)
efforts, notable exceptions being Botswana, Namibia and South Africa. Prevention success is less immediately visible and harder to measure than treatment success. It is extremely difficult to attribute incidence
decline to specific programmes or elements of programmes, particularly those addressing social and behaviour change and structural factors. Growing emphasis on demonstrable results and cost-effectiveness
measures per infection averted inhibits the availability and sustainability of funding for HIV prevention,
and may also favour biomedical approaches, including treatment for prevention, over socio-behavioural
and gender-transformative approaches. In reality, these are interlinked: all biomedical approaches require
behaviour and/or social change and, conversely, social transformation and behaviour change programmes
need to include the potential uptake of biomedical options.
In addition, the past few years have witnessed universal excitement generated by AIDS becoming, for many
people, a life-long treatable condition, leading sometimes to increased risk behaviours. Yet this ignores
the personal challenges of living with HIV and accessing life-long medication, the huge care burden on
women and girls, and multiple risks and uncertainties. At the national level, failure in prevention in highly
impacted countries means that the costs of providing ART for life will become unsustainable if numbers
continue to rise. Effective prevention is vital for treatment success and new and improved approaches
to treatment3 need, likewise, to maximize the benefits for prevention. We need to recognize the mutual
inter-dependence of prevention and treatment, not polarize them, and to see prevention expenditures
as an essential cost-saving investment in long-term health and development. Men, women and young
people living with HIV are key partners in this endeavour, whose potential contributions have yet to be
fully realized.
4.3.2 Limited access to treatment to SRH and HIV services
Effective integration of sexual and reproductive health and HIV prevention has long been recommended
and guidelines developed, but many opportunities for integration are still missed. Less than one-third of
African women have access to the reproductive health care they need, 215 000 women die annually of
pregnancy-related causes, and Africa has the highest rate of adolescent pregnancy in the world, with attendant risks for HIV infection, unsafe abortion, morbidity and death (Gerntholtz & Grant, 2010). Maternal
mortality is greatly worsened by HIV and AIDS, and Africa will fail to meet international targets (including
MDG 5 and High Level Meeting targets) until all four prongs of PMTCT are implemented: halving HIV
incidence in women; reducing unmet need for family planning; providing antiretroviral prophylaxis to
prevent HIV transmission during pregnancy, labour and delivery, and breastfeeding; and providing care,
treatment and support for mothers and their families.
3. UNAIDS makes a number of recommendations for improving treatment modalities summed up as Treatment 2.0 (UNAIDS, 2010).
36
4.3.3 Lack of access to prevention commodities
Access to female condoms remains far too low in the region. This is compounded by poor supply and
distribution management and ineffective promotion by the public sector. Demographic and Health Survey
(DHS) data in various countries show that, where supplies of male and female condoms have increased,
including through social marketing, so has reported use. In some countries, religious and cultural resistance to effective prevention methods, such as male and female condoms, is another barrier to effective
prevention. A key issue to resolve is inconsistent condom use, particularly in long-term discordant couples
and where there are concurrent relationships. In casual and transactional sex, and among young people,
condom uptake is generally much higher if access is assured. In some countries, such as Zimbabwe, interest and uptake of female condoms was significant when availability was high, and indications show that
new models of female condom may also be more acceptable than the original femidoms.
The lack of other prevention methods that women can use, for example pre-exposure prophylaxis (PrEP)
including microbicides, has been another gap in the prevention response, although exciting developments are now emerging in various trials. These include follow-up trials to the CAPRISA 004 trial of one per
cent tenofovir gel, which achieved 39 per cent reduction in new infections in women in a South African
cohort. This is not just proof of the concept that antiretroviral drugs can prevent HIV acquisition, but also
that microbicides can work as a method of delivery women and their partners have shown willingness
to use them (McCormack, 2010).
4.3.4 Gaps in HIV prevention knowledge and understanding
Women and girls, and men and boys need to understand much more than the UNGASS comprehensive
knowledge indicator for HIV that measures very basic factual knowledge. Instead, they need to know
why concurrency is a particularly risky form of sexual networking, the protective benefit of condoms and
how to negotiate and use them with a partner, how male circumcision reduces risks for HIV acquisition
and for cervical cancer in women and, equally, that it is not 100 per cent effective. They need to know that
having other sexually transmitted infections (even if not symptomatic) facilitates HIV transmission and risk,
and that anal sex is particularly risky in both homosexual and heterosexual relationships. They need the
knowledge that, in high prevalence epidemics, much transmission occurs in long-term partnerships, not
just through commercial and casual sex or men having sex with men. It is also important to know that men
and women living with HIV can still have safe and pleasurable sex and how to achieve this, and that safe
ways to achieve conception exist, although they may need to fight for access to information and services.
They need to redefine risk in relationships and understand that a stable couple can remain discordant for
HIV for a long time, so both partners should be tested and counselled together.
4.4 Protecting women and girls from HIV
Protecting girls and women from HIV requires inter-related combination approaches that address immediate risk factors, especially: reduced age-disparate sex; fewer sexual partnerships and reduced concurrency;
wide-scale medical male circumcision; delayed sexual debut; and consistent male and female condom use.
In addition, the more distal factors also need to be addressed, such as mobility, socio-economic and gender inequality and inequity, violence, alcohol use, punitive laws and other structural factors. Schwartlnder
et als (2011) investment framework highlights as critical enablers the underlying social and programmatic
factors that are vital for prevention success (Schwartlnder, et al., 2011).
In the long term, reducing gender inequalities of wealth, social status, education, and realizing legal and
human rights may go some way to reducing age-disparate sex and the extent of multiple and concurrent partnerships by young women, and increase womens capacity to negotiate safer sex through male
or female condom use and microbicides when available. In the short term, expanding knowledge and
competencies around HIV and AIDS through comprehensive sexuality education and related life-skills
development with young people, multi-dimensional social transformation and behaviour change strategies, and generating accurate personal risk perception, are essential. Approaches should prioritize those
groups most at risk and, where incidence is highest, develop a protective and enabling environment for
young women to put their knowledge and skills into practice. We also need to work intensively with boys
and men to change perceptions, behaviours and values so that they see gender equality and equity as
beneficial to them too.
37
4.5 Revolutionizing HIV prevention
As treatment improves in quality, access and uptake, with realistic aspirations to achieve universal access by
2015 in more countries, HIV prevention must nonetheless remain the cornerstone of epidemic responses.
Success in prevention is vital to achieve sustainable universal access to care and treatment and to mitigate
the impacts of AIDS on communities, families and individuals.
In order to progress towards zero new infections in eastern and southern Africa, to achieve MDGs 3, 4, 5
and 6 and to realize the EAC and SADC commitments to halving the number of new infections by 2015
and virtual elimination of MTCT now ratified globally by the UN General Assembly in June 2011 we
need to revolutionize our approach to prevention.
In his 2011 Letter to Partners, UNAIDS Executive Director Michel Sidib outlines a set of six new frontiers
to move the global AIDS response forward: the democratization of the response; making the law work for,
not against, AIDS; reducing the upward trajectory of programme costs; making funding for AIDS a shared
responsibility; making the AIDS movement a bridge to development; and fostering scientific innovation
for HIV prevention and treatment (Sidib, 2011).
The UNAIDS 20112015 Strategy, Getting to Zero: stresses generating the highest political commitment, mobilizing communities to demand transformative change and allocating sufficient resources to epidemic
hotspots, to achieve the revolution in prevention (UNAIDS, 2010). The 2011 UN General Assemblys Political
Declaration on HIV/AIDS is an important platform on which to build intensive advocacy and support, to
ensure national plans and programmes address the targets efficiently and effectively, despite the challenges of diminishing international funding. The UNAIDS Outcome Framework (20102011) fully recognizes
the importance of human rights and gender equality in the HIV response, including the need to counter
gender violence and address the needs of girls and women throughout their lives.
Transformation of gender roles and norms, of dominant, risk-taking masculine stereotypes and feminine
stereotypical dependency, are essential in the wider political discourse and programmatic orientation for
prevention. The Agenda for Accelerated Country Action for Women, Girls, Gender Equality and HIV, 20102014,
provides important guidance and commitment towards making this a reality (UNAIDS, 2010).
Prevention needs a wider leadership and organizational base than treatment, which is clearly spearheaded
by the health sector. Prevention needs multifaceted and multisectoral approaches involving all sectors
and multiple players and, in particular, strong social movements to demand prevention as well as treatment and care.
Health sector investments in prevention are very important, and need to increase. There is also overlap
with treatment expenditures, for instance regarding HIV testing and counselling (HTC). HTC has increased
five- to six-fold over the past five years in ESA, with greatly increased uptake of services to prevent motherto-child transmission, for health provider-initiated HTC, and among young people.
4.5.1 Emerging and promising strategies
Promising and emerging biomedical HIV prevention approaches (including recent developments in microbicides and pre-exposure prophylaxis, and voluntary medical male circumcision) should show significant
results at population level, for both women and men, in the coming years.
Recent efficacy data on antiretroviral treatment (ART) for prevention, the HPTN 052 trial (WHO; UNAIDS,
2011), found 96 per cent reduction in HIV transmission in discordant couples in a randomized controlled
trial with sites in four continents. Antiretrovirals in microbicides and for pre-exposure prophylaxis also
show some promise for HIV-negative partners to stay negative. The proof of concept is there, although
major challenges need to be addressed in programming and financing early antiretroviral treatment to
prevent viral transmission, and ARV prophylaxis to prevent sexual HIV acquisition. With respect to gender,
the challenge to get men on to treatment is greater than the challenge to reach women who typically
access health services in general and HIV testing in much larger numbers.
Important emerging strategies include couples counselling and testing, getting discordant couples onto
effective microbicides, PrEP or ART, and starting ART treatment early for pregnant HIV-positive women.
Couple testing and counselling require well-trained counsellors and strong follow up, particularly for dis-
38
cordant couples, to reduce risks of gender violence and other negative consequences. The World Health
Organization (WHO) is currently finalizing guidelines on couples counselling and testing and for early
initiation of antiretroviral treatment in discordant couples, for adoption and country adaptation.
Medical male circumcision is also being rolled out aggressively in countries such as Swaziland and Kenya,
and male circumcision policy, preparedness and programming are gaining traction in 11 more countries4
in the region.
Regional Economic Communities and international partners are making great strides in programming to
address gaps and challenges of comprehensive sexuality education (CSE) in current school-based HIV and
life skills programmes in ESA (UNESCO, 2011). Quality CSE, including specific attention to gender norms,
can impact on sexual behaviour, health outcomes, and non-health outcomes such as critical thinking,
decision-making and realizing human rights (UNAIDS, UNESCO, UNFPA, UNICEF, WHO, 2009) (UNESCO,
2011). Evidence from effective programmes demonstrates the need for programmes that begin sexuality
education before young people become sexually active. CSE should include information on relationships,
gender norms and gender equality, sexual behaviour and a range of HIV and pregnancy prevention options including abstinence, condom use and other contraception. The most cost-effective programmes
are those that are rolled out within a school curriculum and not delivered as a voluntary extra.
4.6 Recommendations
Reference is made in other papers to many international and Africa-regional pledges, declarations and
commitments regarding gender equality and equity, health expenditure, and sexual and reproductive,
gender and human rights. Recommendations have been made regarding laws and policy, meaningful
male and youth involvement, programmatic linkages, reducing gender violence, the active involvement
of women and men living with HIV (Positive Health Dignity and Prevention), and other key concerns. They
are critical for HIV prevention, among other human and gender rights, and strong and effective advocacy
is need.
In brief, some key technical ways forward for prevention programming are reflected below.
4.6.1 Know the epidemics, the evidence and the national responses
The basis for effective HIV prevention is sound analysis and understanding, with a gender perspective,
of the regional, national and local epidemics. This needs updated, strategic information and reliable data
disaggregated by sex, age (and other variables) to highlight where new infections are occurring, the trends
in incidence, proximate and distal factors driving the epidemics, and the evidence for what is working in
different settings to reduce the rate of new infections.
Key to effective responses is targeting efforts to where the most new infections are occurring and, particularly in generalized epidemics, including protection for women and girls in long-term partnerships. This
requires that countries understand their epidemics thoroughly, including a gender analysis, and combining
modelling of transmission with triangulation of quantitative and qualitative data from different sources,
as countries in ESA have increasingly done. It also requires improved measurement of incidence by age
and gender, geographical locality and other demographic factors, to demonstrate the efficiency and effectiveness of combination prevention and to ensure sustainable financing of strategies that demonstrate
measurable results.
4.6.2 Prioritize and bring to scale quality prevention strategies that work
In their national strategic frameworks and plans, countries need to prioritize and scale up evidenceinformed, quality, costed and budgeted combination approaches that are fully and effectively gendered
throughout, in order to avert new infections where they are highest and, particularly, in women and adolescent girls. Men older than 25, not just young men, need to be very much in focus too, with regard to
their own HIV acquisition as well as transmission to younger women. Reducing multiple and concurrent
4. The priority countries, in addition to Kenya and Swaziland, are Botswana, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Tanzania, Uganda, Zambia
and Zimbabwe.
39
partnerships by men and women, achieving high rates of male circumcision and optimizing condom use
in situations where evidence shows results can be achieved are three immediate and essential approaches.
The potential for antiretrovirals to contribute to HIV prevention needs full exploration and research. Meanwhile, disproven strategies should be dropped from prevention funding and scarce resources should not
be wasted on poorly implemented programmes. Schwartlnder et als investment framework highlights
priorities for action, depending on the epidemic setting, and critical social and programming factors to
guide prevention investments towards results (Schwartlnder, et al., 2011).
4.6.3 Ensure effective monitoring and evaluation
Programmes need to include clear sex and age differentiated baselines with ambitious targets and SMART
(specific, measurable, achievable, relevant and time-based) indicators, so that monitoring and evaluation
guide the most cost-effective and cost-beneficial ways forward. Biomarkers to evaluate impacts of interventions are increasingly important.
4.6.4 Address gender inequalities and inequities
Gender inequalities and inequities that fuel the epidemic must be addressed through gender-transformative approaches that reduce HIV transmission and risk, among many other fundamental societal, community and individual benefits. Both males and females need support to understand and reassess gender
stereotyping, roles and norms, to prevent and address gender violence, enshrine the rights of women
and girls and to understand the mutual benefits of unlocking each others potential for safe sex and for
caring and satisfying relationships.
4.6.5 Link HIV and AIDS responses effectively with SRH and other health needs and rights
Entry points for health, particularly sexual and reproductive health, should be optimally used to integrate
HIV prevention strategies, testing and counselling, male circumcision, risk assessment and so forth. Likewise,
HIV-related prevention and treatment services should incorporate wider aspects of sexual and reproductive health and rights, with sensitivity to gender and age-related needs. Women of reproductive age and
their partners need quality services in health facilities and community mobilization for all four prevention
of mother-to-child prongs to avoid transmission to infants:
1 prevention of primary infection in the mother and partner;
2 prevention of unintended pregnancy;
3 provision of antiretrovirals for mother and child to prevent transmission; and
4 access to care and antiretroviral therapy for mothers and their children.
The World Health Organizations updated PMTCT Guidelines (World Health Organization, 2010) provide
clear options for countries to adopt or adapt. Ensuring mothers survive is as critical as preventing transmission to the infant, as enshrined in the Global Plan towards the Elimination of New Infections among Children
by 2015 and Keeping their Mothers Alive (UNAIDS, 2011), with 22 priority target countries.
4.6.6 Ensure wide roll-out of quality sexuality education
It is imperative to reach a critical mass of young people with comprehensive sexuality education (CSE) that
addresses information, values and skills. The potential of CSE to change risky behaviour, as a foundation
for social transformation, build gender equity, enhance the capacity of young people to be productive
citizens and to reduce poverty can only be developed, implemented, scaled up and sustained if the larger
environment is favourable. This requires building support through advocacy, alliance-building, policy
development and enactment.
40
4.7 Conclusion
Characteristics of effective HIV prevention can be summarized as being rights-based, scientifically accurate
and grounded in evidence, culturally appropriate and gender-responsive, age-specific, and participatory
and inclusive (UNESCO, 2010). The Accelerated Agenda for Women and Girls (UNAIDS, 2010) also emphasizes
the need to understand and respond to how the epidemic impacts on women and girls, translate political
commitments into scaled up action to address their needs and rights, and ensure an enabling environment
to fulfil their human rights and empowerment in relation to HIV. In the words of Michel Sidib, Executive
Director of UNAIDS: Can we prevent the 7400 HIV infections that occur each day? Yes, but it will require nothing
short of a prevention revolution (UNAIDS, 2010), with social and gender transformation as a critical pillar.
The HIV prevention train has had a huge push from the platform of the UN General Assembly Political
Declaration (UN General Assembly, 2011); it is definitely rolling out of the station. We all need to ensure it
stays on track, gains momentum and reaches its destination on schedule.
4.8 References
Gerntholtz, L., & Grant, C. (2010). International, African and country legal obligations on womens equality in relation to
sexual and reproductive health, including HIV and AIDS. Durban: HEARD and ARASA.
Leclerc-Madlala, S. (2009, vol 6). Cultural scripts for multiple and concurrent partnerships in southern Africa: why
HIV prevention needs anthropology. Sexual Health, pp. 103110.
McCormack, S. (2010). The CAPRISA 004 Result in Context. MRC Clinical Trials Unit presentation to International AIDS
Conference, 20 July 2010. Vienna.
Schwartlnder, B., Stover, J., Hallett, T., Atun, R., Avila, C., Gouws, E., et al. (2011, June 3). Towards an improved
investment approach for an effective response to HIV/AIDS. The Lancet.
Sidib, M. (2011). Letter to Partners. Geneva: UNAIDS.
UN General Assembly. (2011). Political Declaration on HIV/AIDS: Intensifying our Efforts to Eliminate HIV/AIDS.
UNGASS. New York: UN.
UNAIDS. (2010). Getting to zero: 20112015 Strategy of the Joint United Nations Programme on HIV/AIDS (UNAIDS).
Geneva: UNAIDS.
UNAIDS. (2011). Global Plan towards the Elimination of New Infections among Children by 2015 and Keeping their
Mothers Alive. Geneva: UNAIDS.
UNAIDS. (2010). Outlook Report. Geneva: UNAIDS.
UNAIDS, UNESCO, UNFPA, UNICEF, WHO. (2009). International Technical Guidance on Sexuality Education, Volume I:
The rationale for sexuality education. Paris: UNESCO.
UNESCO. (2011). School-Based Sexuality Education Programmes: A Cost and Cost-Effectiveness Analysis in Six Countries.
Paris: UNESCO.
UNESCO. (2010). Short guide to the essential characteristics of effective HIV prevention. Paris: UNESCO.
UNICEF. (2011). Opportunity in Crisis: Preventing HIV from adolescence to early adulthood. New York.
United Nations Secretary-General. (March 2011). Uniting for Universal Access: towards zero new HIV infections,
zero discrimination and zero AIDS-related deaths. UNGASS Agenda Item 10: Implementation of Declaration of
Commitment on HIV/AIDS and the Political Declaration on HIV/AIDS. New York: United Nations.
WHO; UNAIDS. (2011, May 12). Groundbreaking Trial Results confirm HIV treatment prevents transmission of HIV.
Geneva.
World Health Organization. (2010). Antiretroviral drugs for treating pregnant women and preventing HIV infection in
infants: recommendations for a public health approach. Geneva: WHO.
Adopting a multi-stakeholder approach to address violence against women and HIV
Adopting a multistakeholder approach

to address violence
against women and HIV
5.1 Introduction
Over the last decade, evidence has emerged that Violence Against Women
(VAW) presents a serious risk factor for HIV (Campbell, 2002) (Dworkin & Ehrardt,
2007) (World Health Organization, 2005). Studies demonstrate a two-way link
between VAW and HIV. VAW prevents women and girls from engaging in safe
sexual practices and disclosing their HIV status which then hinders efforts to
curb HIV (Hale, Vazqueaz, & Welbourn, 2011). A study conducted in Kenya also
noted that pregnant women living with HIV report discrimination, disparaging
remarks and general mistreatment when accessing care (Turan, Bukusi, Onono, Holzemer, Miller, & Cohen, 2010). The study attributes this to the fact that
pregnant women are more likely to be the first to test for HIV in the family and,
therefore, assumptions are made that they are the source of the virus. This is due
to the lack of understanding of transmission mechanisms or the HIV window
period (Turan, Bukusi, Onono, Holzemer, Miller, & Cohen, 2010).
Despite the acknowledgement of the link between VAW and HIV, most governments
have been responding to the two issues separately, without explicitly drawing the
links thereof to inform policies. Linking responses to VAW and HIV is a daunting task
that requires concerted effort of multiple stakeholders. As the Center for Womens
Global Leadership and Health notes, VAW and HIV remain ... largely separate and
distinct areas of work. (Rothschild, Reilly, & Nordstrom, 2006).
Experience drawn from past initiatives undertaken by civil society, governments
and international development partners have culminated in recommendations
to link VAW and HIV and treat VAW as a violation of human rights. For instance,
UNAIDS Agenda for Accelerated Country Action for Women, Girls, Gender Equality and
HIV, 20102014, recommends that all forms of violence against women and girls be
recognized as a violation of human rights (UNAIDS, 2010). In addition, the Committee on the Elimination of Discrimination Against Women and the African Protocol
on Womens Rights also advocate for treatment of violence against women as a
violation of human rights.
This technical paper builds on the body of evidence from the United Nations and
other development partners, including the UNAIDS recommendations cited above.
The paper seeks to underline the importance of adopting a multi-stakeholder approach in addressing HIV and AIDS. Women at different stages of life have different
developmental needs from each other. Besides, women live in diverse communities
where the degree of human rights violation varies. Evidence shows that a multiple
stakeholder approach is invaluable in addressing VAW. Furthermore, the complex
UNICEF/NYHQ2010-1466/Noorani
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42
linkages between VAW and HIV create an impetus to adopt an approach that encompasses use of multiple stakeholders in addressing them. A well-coordinated multi-stakeholder approach helps to harness
comparative advantages and thereby enhances effectiveness and collective purpose in the fight against
VAW and HIV.
5.1.1 Definition of violence against women
The Declaration on the Elimination of Violence Against Women adopted by the United Nations General
Assembly defines violence against women as:
any act of gender-based violence that results in, or is likely to result in, physical, sexual or mental
suffering to women including threats of such act, coercion or arbitrary deprivation of liberty
whether occurring in public or private life (UN General Assembly, 1994).
This paper adopts this definition and focuses solely on violence against women and girls in the context
of current international human rights norms and standards.
Drawing from the womens empowerment framework discussed below, this paper presumes that addressing VAW and HIV entails dealing with the root causes of the two problems by empowering women.
Womens empowerment can be facilitated through interventions that provide resources and opportunities
for women and re-shape socio-economic circumstances that fuel gender inequalities. Womens empowerment interventions should instil behaviour change that will impact positively on VAW and HIV interventions.
Recommendations have been made to recognize VAW as a form of human rights violation and to link VAW
and HIV interventions, which may be useful strategies as long as recognition is paid to the complex reality
of females not being a homogenous group: women and girls have different developmental needs from
each other and live in diverse communities where the degree of rights violations differ. Research demonstrates a strong link between gender inequality and the degree of vulnerability to VAW and HIV. Studies
conducted in South Africa (Wechsberg, Parry & Jewkes, 2008) show that interventions on VAW and HIV
are most effective when they remain sensitive to gender and cultural differences and expectations, and
address social and economic inequalities that increase the vulnerability of women and girls to VAW and HIV.
If VAW should be treated as a human rights violation, and if interventions to reduce VAW should integrate actions to address HIV simultaneously, then these interventions should focus on addressing gender
inequality as the primary underlying cause of both VAW and HIV. In this paper, Kabeers framework of
womens empowerment (Kabeer, 2003) is applied to provide insight on inter-related dimensions of women
empowerment. While other frameworks on womens empowerment exist, such as social relations1 and
Sarah Longwes (Longwe, 1999), Kabeers framework was found to be useful due to its elaboration on
linkages between resources, opportunities and orientation of achievement, which assists in clarifying the
entry points for the multiple stakeholder approach supported in this paper.
5.1.2 Womens empowerment framework
Kabeer suggests that the concept of empowerment can be explored through three closely interrelated
dimensions (access, agency and achievement or outcomes) (Kabeer, 2003). Access to resources is a precondition for empowerment. The term agency denotes the ability to use the available resources to
bring about new opportunities and the ability of policy makers to adopt a new orientation of outcomes
of intervention. Desirable outcomes are those that transform the prevailing inequalities in the societies
so that women are able to exercise choice in a manner that challenges power relations. Consequently,
Kabeer suggests that meaningful empowerment entails changing the way women see themselves and
their capacity for action. The implications of Kabeers framework are that empowering women occurs
through building capabilities of women, providing resources and ensuring that outcomes of intervention
are valued, based on womens ability to transform prevailing inequalities.
1. Social framework approaches suggest that informal relationships have an important effect on an individuals behaviour. Sarah Longwes womens empowerment
framework disaggregates levels of empowerment to highlight different needs of women at different levels of empowerment.
42
Experience from past initiatives supports Kabeers theory. The Intervention with Microfinance for AIDS
and Gender Equity (IMAGE) programme used a multi-stakeholder approach, providing resources and opportunities and a new orientation of desired outcomes, resulting in womens empowerment in the study
location in South Africa. Women within the intervention area were offered micro-finance loans that were
conditional on participating in a one-year gender training programme called Sisters for Life, addressing economic poverty and gender inequalities simultaneously, in the context of high intimate partner
violence and a severe HIV epidemic. A cluster randomized trial found that women who participated in
IMAGE showed improvement in personal empowerment, reduced HIV risk behaviour and increased skills
in collective action (Kim, et al., 2009). Kabeers notion of empowerment is therefore buttressed by positive
experiences from interventions in the region.
5.1.3 Review of integrated VAW and HIV programmes
National governments, regional bodies, international partners and civil society have continued to step up
interventions on VAW and HIV. Although this paper cannot possibly capture all the initiatives in addressing VAW and HIV, a few illustrations are summarized below, showing the role and contributions of various
stakeholders, including governments, international organizations, regional economic commissions and
civil society organizations.
Most country governments have demonstrated a willingness to address VAW and HIV, among other gender concerns, by assenting to international, continental and regional commitments. Furthermore, most
countries have successfully promulgated laws and developed policies that seek to address VAW and HIV
(with a few exceptions). However, evidence suggests that wide gaps exist in the implementation of laws
and policies on VAW and HIV. For example, South Africa has impressive laws and policies designed to curb
VAW and to address HIV. South Africa is one of the countries hailed by the Convention on the Elimination
of All Forms of Discrimination against Women (CEDAW) secretariat for adopting innovative practices in
the fight against VAW and HIV for the implementation of Thuthuzela (discussed below). Yet, the 2010
CEDAW report noted concerns about lack of information on specific initiatives to address the intersection
between VAW and HIV. Also, CEDAW was concerned about prevailing high levels of stigma and discrimination against people living with HIV. CEDAWs concerns demonstrate that the implementation of policies
still remains challenging, even in countries that have a favourable legal and policy environment in place.
Some countries have gone even further, by developing laws that change the gender inequality landscape
and provide opportunities for womens empowerment. Kenya has recently passed a constitution that
provides for womens empowerment in socio-economic and political spheres, although implementation
of the constitution presents a challenge. Mozambique has recently passed a Domestic Violence Act that
is set to protect women from patriarchal tendencies. Rwanda and Tanzania have pursued policies that
have catapulted women into high-ranking positions.
There have also been some innovative initiatives to address VAW and HIV. South Africa has adopted an
innovative practice called Thuthuzela2 to manage rape cases. Thuthuzela is an integrated approach, designed to integrate rape care services with the intention of reducing secondary trauma for rape victims.
It is operated in public hospitals or communities where incidence of rape is high. Firstly, rape victims are
transported to a dignified place of care (Thuthuzela) where the victims are counselled, provided with
medical treatment and granted access to investigators to pursue legal action. In addition, the injured party
is provided with referral for long-term counselling and is transported home or to a place of safety by an
ambulance or an investigation officer when s/he has received all the necessary services. The Thuthuzela
system has reduced secondary trauma, increased conviction rates and shortened lead times in prosecuting rape cases.
Regional bodies have called on governments to take initiatives in fighting VAW and HIV by identifying
gender problems and developing gender orientated protocols. For instance, the SADC Protocol on Gender
and Development calls on Member States to reduce existing levels of VAW by 50 per cent and to enact
and enforce legislation prohibiting all forms of gender-based violence by 2015.
International development partners have played an important role in supporting initiatives geared towards
addressing VAW and HIV. The UN and bilateral donors have supported capacity building work as well as
2. Thuthuzela is a Xhosa word that means comfort. See: http://www.unicef.org/southafrica/hiv_aids_998.html
42
national initiatives to develop gender progressive policies. In Kenya, the UN was among the organizations
that funded a pioneer gender progressive bill on Sexual Offence.
Civil society has been instrumental in working with governments and/or communities in addressing
VAW and HIV. A number of civil society organizations, such as the Sonke Gender Justice Network, have
been active in promoting the participation of men and in promoting approaches in VAW and HIV that are
relational rather than confrontational.
5.2 Challenges and opportunities
Although VAW is endemic in many communities across the world and cuts across race, age, religion and
national boundaries, addressing VAW and HIV in Africa has also experienced challenges posed by cultural
and traditional practices such as female genital mutilation and wife inheritance.
The fact that VAW and HIV are addressed separately in policy-making further compounds the problem
since the opportunity to focus on both issues jointly, in the light of the countrys social economic context, is lost. Addressing VAW and HIV separately results in a loss of opportunity to achieve synergy from
resources committed to the two courses separately. Given the competition for fiscal resources between
social and infrastructure needs, it is important to adopt a multi-stakeholder approach so as to coordinate
and use available resources better.
This paper does not attempt to document all gaps and challenges in integrated VAW and HIV interventions.
However, fragmented approaches that fail to harness available resources and opportunities in a manner
that promotes synergy between multiple stakeholder has been a common failure in the past. Effectively
addressing VAW and HIV requires approaches that pool a continuum of stakeholders, to make different
contributions in regard to availing resources and opportunities and building capability of men and women
to transform circumstances that resonate with inequality.
One important input in empowerment is the availability of resources. Yet, allocation of resources to meet
gender-oriented goals tends to be accorded a low priority in the majority of countries. An Organization
for Economic Co-operation and Development (OECD) Issues Brief points out that most governments do
not commit sufficient financial resources or consciously promote gender-responsive budgeting, despite
the fact that this would ensure that gender issues are mainstreamed in sectoral priorities and accounted
for in annual reports (OECD, 2010). Gender-responsive budgets incorporate a gender perspective at different levels of the budgeting process and restructure revenue and expenditure in a manner that promotes
achievement of gender-equality orientated goals. The OECD brief cites weak political will, lack of sex-disaggregated data and lack of capacity as some of the hindrances to adopting gender-responsive budgets.
Despite the above challenges, there are a number of opportunities that present themselves in the region.
These opportunities are a form of resource that governments could capitalize on, to step up efforts towards
empowering women and addressing VAW and HIV.
5.2.1 Opportunities from international partners
At the international level, the United Nations and some bilateral donors have made commitments that
translate into opportunities for intervention to address the challenge of VAW and HIV.
5.2.1.1 UN Millennium Development Goals Acceleration Programme
After the MDG Summit in September 2010, the United Nations undertook to assist Member States who
lag behind in meeting their commitments towards achieving the MDGs. Recognizing that equality for
women and girls represents an economic and social imperative, UN and Member States have agreed to
scale up efforts to improve equality for women and girls through investing in and empowering them. The
programme is spearheaded by the UNDP and it presents an opportunity for countries to close the gaps
between commitments and realities.
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5.2.1.2 UN Africa UNiTE Campaign
The Africa UNiTE Campaign is part the United Nations Secretary-Generals global campaign, presenting
a continent-wide partnership to end violence against women (Africa UNiTE Campaign). The Campaign
gives a voice to speak up and speak out, in order to prevent violence, provide services to survivors and
promote justice. The campaign aims to raise public awareness and increase political will and resources
for preventing and responding to all forms of violence against women and girls in Africa. The expected
result is the creation of a favourable and supportive environment for governments to fulfil existing policy
commitments, in partnership with civil society, experts and UN organizations and other stakeholders.
The campaign covers a number of issues that are manifestations of violence against women, by emphasising six focus areas. Recognizing that violence against women is both a cause of and a consequence of
the feminization of the HIV and AIDS pandemic, the campaign has prioritized linkages between violence
against women and girls and HIV and AIDS as one of the focus areas.
Moreover, as part of the growing effort to include men in efforts to eradicate VAW, the United Nations
Secretary-General launched his network of male leaders. The network supports the work of men around
the world to defy negative stereotypes, embrace equality and inspire men and boys to speak against
violence. Leaders of the network are drawn from different sectors and work in their spheres of influence
to end VAW.
5.2.1.3 UN Trust Fund to End Violence Against Women
The UN Trust Fund is a global multilateral grant-making mechanism, aimed at supporting national efforts
to end violence against women and girls. The fund has been applied in advocating for implementation
of laws grounded on human rights, broadening awareness of human rights, promoting access to services
and developing capacities in development.
An important insight is that, in line with the Africa UNiTE Campaign, the UN Trust Fund has prioritized the
link between VAW and HIV in order to generate a pool of best practice, lessons learnt and what works
in addressing the link between VAW and HIV. Recently, countries like Botswana have benefited from the
Trust Fund to address the VAW and HIV through Botswanas Department of Womens Affairs. Botswanas
programme applies a multi-stakeholder approach that involves the police, the Department of Gender
and the Department of Health.
5.2.2 Opportunities from bilateral donors
Bilateral donors (also known as development partners) have continued to support interventions aimed
at addressing VAW and HIV. Some opportunities that present a form of resource for Africa are listed here,
although it is not an exhaustive list. The United States Presidents Emergency Plan for AIDS Relief (PEPFAR)
and the Ford Foundation have also prioritized responses to VAW and HIV and set up funds to support
governments and civil societies in responding to VAW and HIV. Some bilateral donors support civil society
work that addresses VAW and HIV jointly in the region, such as the Canadian International Development
Agency. The New Partnership for Africas Development's (NEPAD's) Spanish Fund for African Women Empowerment supports women empowerment projects across the continent. The Swedish International
Development Cooperation Agency (Sida) and the Ford Foundation have supported VAW and HIV interventions in southern and eastern African, including support for the MenEngage Africa Symposium held
in Johannesburg in 2009, which culminated in the creation of mens networks to galvanize mens support
for gender orientated work.
5.2.3 Civil society organisations
In some cases, the capacity of civil society organizations in Africa is weak. However, there are reports that
this situation is improving. A recent study by the Southern Africa Trust indicates that the capacity of civil
society organizations has improved significantly in the past decade as a result of interventions aimed at
developing the capacity of civil society (Southern Africa Trust, 2011). Some examples of civil society initiatives that are providing exceptional leadership in addressing VAW and HIV as inter-linked concerns include
the Women Wont Wait, One in Nine Campaign in South Africa and the VAW prevention network that is
facilitated by Raising Voices in Uganda.
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5.2.4 Involving men in addressing VAW and HIV
Civil Society organizations have spearheaded initiatives that have seen the entry of men and boys into a
terrain that was traditionally dominated by women. Certain civil society organizations, such as Homens
pela Mudana (Mozambique), the Voluntary Service Overseas Regional AIDS Initiative of Southern Africa
(VSORAISA) and the Sonke Gender Justice Network (South Africa) have promoted the involvement of
men in VAW and HIV. Although patriarchal beliefs and control remain a challenge in the region, men are
becoming more aware of the common destiny they share with women and some have formed networks
to promote a change in attitude and to support gender work in general.
The glaring gap in this area is that government policies and programmes, mainly, do not explicitly provide
information on how men and boys should be involved in addressing the challenges of VAW and HIV. Male
involvement is therefore ad hoc and mainly spearheaded by civil society. Despite this policy omission,
most initiatives that have succeeded in combating VAW and HIV as inter-linked concerns have included
men as important stakeholders.
A case in point is the Stepping Stones model. Stepping Stones is a community development intervention,
aimed at improving sexual health by building better and more gender equitable relationships. The model
applies participatory learning approaches that aim to transform construction of gender and masculinity,
in order to change societal norms. A randomized control trial conducted in South Africa found that the
Stepping Stones model impacted on biological outcome by reducing infection with new herpes simplex
virus 2 (HSV-2). As such, a behavioural intervention that involved men and women collectively in deliberating on challenges and finding solutions was found to have a high potential for success (Jewkes R, 2008).
5.3 Recommendations
This paper emphasized the need to use a multi-stakeholder approach in addressing VAW and HIV. Examples
of initiatives that are successful in addressing VAW and HIV as a result of involving multiple stakeholders
have been presented, including Stepping Stones and Thuthuzela. Opportunities are available at the global
level to support governments to address VAW and HIV. Capitalizing on these initiatives requires concerted
effort and identification of champions to drive processes, since opportunities do not last for an indefinite
period of time.
5.3.1 Develop a policy framework to guide joint VAW and HIV programming
While government resources exist to address VAW and HIV, these resources largely remain uncoordinated.
Governments should, in collaboration with development partners, develop a framework to guide interventions on VAW and HIV so that stakeholders understand their role and the appropriate entry points for
their intervention. The Thuthuzela approach cited in this paper offers an example where clarity on the role
of different sectors has led to successful implementation.
5.3.2 Build capability across multiple stakeholders
Government and development partners should create a knowledge-sharing platform that regularly brings
together stakeholders from different sectors to share experiences and innovations and promote crosspollination of ideas on best practices.
5.3.4 Reorient outcomes to achieve transformative change
To promote sustainability of initiatives, governments and development partners should apply monitoring
and evaluation frameworks that focus on achieving a transformative action across the range of stakeholders, rather than merely focusing on womens empowerment.
42
5.4 Conclusion
In conclusion, mobilizing resources, building capabilities and reorienting outcomes for the empowerment
of women calls for closing gaps identified in this paper. It also necessitates building or solidifying partnerships that are motivated by a collective purpose. Gaps identified in the paper include: failure to allocate
resources to gender goals in national budgets; failure to tap into emerging resources such as empowered
women; failure to include boys and men in government policies on VAW and HIV; as well as inadequate
monitoring of outcomes of intervention at national and regional levels.
Drawing from the prepositions of Kabeers framework which perceives access to resources, agency (which
involves building the ability to use resources) and an orientation in outcome as necessary conditions for
promoting equality, the paper makes recommendations for interventions that promote access to resources,
build capabilities and adopt a transformative orientation of desirable outcome.
5.5 References
Africa UNiTE Campaign. (n.d.). (UN Secretary General) Retrieved from www.africaunitecampaign.org
Campbell, J. (2002, April 13). Health Consequences of Intimate Partner Violence. The Lancet, 359 (9314), pp.
13311336.
Dworkin, S., & Ehrardt, A. (2007). Going beyond ABC to include GEM: Critical reflections on progress in the HIV/
AIDS epidemic. American Journal of Public Health, 97, pp. 1318.
Hale, F., Vazqueaz, M., & Welbourn, A. (2011). Violence against Women Living with HIV/AIDS: A Background Paper.
Washington DC: Development Connections.
Jewkes, R., Nduna, M., Levin, J., Jama, N., Dunkle, K., Puren, A., et al. (2008, August 7). Impact of Stepping Stones
on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial.
British Medical Journal, 337.
Kabeer, N. (2003). Gender Mainstreaming in Poverty Eradication and the Millennium Development Goals: A Handbook for
Policy Makers and Other Stakeholders. Commonwealth Secretariat/IDRC/CIDA.
Kim, J., Ferrari, G., Abramsky, T., Watts, C., Hargreaves, J., Morison, L., et al. (2009). Assessing Incremental Effects
of Combining Economic and Health Interventions: the IMAGE Study in South Africa. Bulletin of World Health
Organization, 87 (11), 824832.
Longwe, S. (1999). Womens Empowerment. In C. March, I. Smyth, & M. Mukhopadhyay, A guide to gender-analysis
frameworks. Oxford: Oxfam.
OECD. (2010). Integrating Gender Equality Dimension into Public Financial Management Reforms. In Gender
Equality, Womens Empowerment and the Paris Declaration on Aid Effectiveness. Paris: OECD DAC Network on
Gender Equality.
Rothschild, R., Reilly, M., & Nordstrom, S. (2006). Strengthening Resistance: Confronting Violence against Women and
HIV/AIDS. New Brunswick: Centerfor Womens Global Leadership.
Southern Africa Trust. (2011). Re-Inventing Civil Society Formations for More Effective Pro-Poor Regional Policy
Influencing in Southern Africa. Johannesburg: Southern Africa Trust.
Turan, J., Bukusi, E., Onono, M., Holzemer, W., Miller, S., & Cohen, R. (2010, September 9). HIV/AIDS Stigma and Refusal
of HIV Testing among Pregnant Women in Kenya: Results from MAMAS Study. AIDS Behaviour, 15, pp. 11111120.
UN General Assembly. (1994). Declaration on the elimination of violence against women. New York: UN General
Assembly.
UNAIDS. (2010). Agenda for Accelerated Country Action for Women, Girls, Gender Equality and HIV. Geneva: UNAIDS.
Wechsberg, W., Parry, C., & Jewkes, R. (2008). Drugs, Sex, Gender Based Violence and the Intersection of the HIV/AIDS
Epidemic with Vulnerable Women in South Africa. Cape Town: Medical Research Council and RTI International.
World Health Organization. (2005). WHO Multi-Country Study on Domestic Violence and Womens Health. Geneva:
WHO.
HIV treatment and care: the concerns for women and girls
HIV treatment and

care: the concerns for
women and girls
6.1 Introduction
The HIV epidemic has a unique impact on women, exacerbated by their roles
within society and their biological vulnerability to HIV infection. Women are
generally at a greater risk of heterosexual transmission of HIV and are twice
more likely to become infected with HIV through unprotected heterosexual
intercourse than men. Additionally, millions of women have been affected indirectly by the HIV epidemic. Womens childbearing role means that they have to
contend with issues such as mother-to-child transmission of HIV and that their
own health may worsen when they get infected with HIV during pregnancy.
Women and girls, especially the elderly, also carry a greater responsibility to
care for people living with HIV.
Over the last decades, governments within the region have committed themselves
to tackling the impact of HIV and AIDS. Notable achievements have been made, in
line with the Millennium Development Goals (MDGs). Despite this progress, there is
an urgent need for cutting edge responses to address the existing gaps in Universal
Access for women and girls. The year 2015 is approaching rapidly and this means
that several of the ambitious global and regional targets are to be achieved within
just a couple of years. These include the: Beijing Platform for Action; Convention on
the Elimination of All Forms of Discrimination against Women (CEDAW); International
Conference on Population and Development (ICPD); Gaborone Declaration on the
Road Map Towards Universal Access to Prevention, Care and Treatment; Brazzaville
Commitment on Scaling up Towards Universal Access; Abuja Call for Accelerated
Action Towards Universal Access to STI/HIV/AIDS, Tuberculosis and Malaria Services
in Africa; Protocol on the Rights of Women in Africa (2003); Solemn Declaration
on Gender Equality in Africa (2004); SADC Protocol on Gender and Development
(2008); and the Sexual Reproductive Health and Rights Plan of Action (known as
the Maputo Plan of Action, 2006). These declarations and commitments guide
the assessment of progress made towards goals and to ensure that all stakeholders
sustain their momentum.
This technical paper will focus on progress made and the remaining challenges in
relation to HIV treatment and care in eastern and southern Africa and, in particular,
the concerns for women and girls.
UNICEF/Leonie Marinovich
48
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6.2 Regional challenges and issues
There are a number of interventions that can be implemented to reduce the burden of the epidemic
among women and girls. These include: promoting and protecting womens human rights; increasing
education and awareness among women; and encouraging the development of new preventative technologies such as post-exposure prophylaxis and pre-exposure prophylaxis, including microbicides. The
following paragraphs will unpack systematically some of the key regional challenges and issues, following the main pillars in a comprehensive HIV and AIDS response: prevention, treatment, care and support.
6.2.1 Improve access to treatment and care
In December 2009, an estimated 3.18 million people in eastern and southern Africa were receiving treatment, up from about 255 600 in 2004 (WHO, UNAIDS and UNICEF, 2010) more than a 12-fold increase
in five years. Despite the progress, for every two people going on treatment, three more become newly
infected with HIV. 1
Contrary to the gender dimension in several other areas related to access to HIV services, the gender
dynamics within treatment show that more women than men are accessing treatment. While this is a positive development and aligned to the proportion of people living with HIV, it has come at a cost. Women
are usually the first to find out about their status and, while they are the ones who access treatment first,
often such treatment comes with negative consequences as a result of stigma and negative impacts
when they disclose their status. It is important to remember that access to HIV testing and counselling
and treatment by men and boys is of pivotal importance in the response to AIDS. Furthermore, access to
treatment for pregnant HIV-positive women for their own health remains low, with the majority of women
in need not accessing antiretroviral therapy. This can largely be attributed to weak health systems, fragmented implementation and poor integration of services that fail to link programmes such as prevention
of mother-to-child transmission with treatment. Wide disparities in coverage and quality of interventions
also exist between countries and even within countries.
The updated World Health Organization (WHO) guidelines for antiretroviral therapy (World Health Organization, 2010) call for earlier initiation of treatment and the use of simpler, more effective drug regimens
in order to reduce morbidity and mortality, as well as vertical and horizontal transmission of HIV, more
effectively (UNAIDS, 2010). However, application of the new guidelines has resulted in an increased number
of people eligible for treatment. Only one country in the region (Botswana) had therefore achieved Universal Access to antiretroviral treatment at the end of 2009. Despite this, five other countries (Mozambique,
Namibia, Rwanda, Swaziland and Zambia) were within striking range of achieving Universal Access targets
by December 2009 (WHO, UNAIDS and UNICEF, 2010).
With competing global priorities and an economic crisis, a longer term sustainable solution is needed
to ensure that governments can keep their commitment to achieve the goal of Universal Access to HIV
prevention, treatment, care and the Millennium Development Goals (MDGs). While the cost of antiretroviral
therapy has decreased rapidly, to approximately US$ 137 per person per annum, it is important to keep
in mind that annually 400 000 young people are newly infected with HIV and will, sooner or later, need
treatment (UNICEF ESARO, 2011). This will push the additional costs for the region close to US$ 55 million
per annum. Preventing these new infections clearly makes business sense.
Treatment 2.0 is a new approach to simplify the way HIV treatment is provided and to scale up access to
care. It consists of a combination of methods, including optimizing drug regimens, simplifying diagnostics,
decreasing costs, improving health system functioning and mobilizing communities (UNAIDS, 2010). Modelling suggests that, compared to current treatment approaches, Treatment 2.0 could avert an additional
ten million deaths by 2025 and lead to a one-third reduction in new HIV infections globally. The eastern
and southern African region continues to be the epicentre of the global epidemic, with an overwhelming
need for treatment. Hence, if investments are focused in this region, a major contribution can be made
towards achieving regional and global targets to halting and starting to reverse the HIV epidemic.
While it is encouraging to discuss new approaches and see the increase in access to treatment in the region, it is important to remember that future treatment needs could be unsustainable if efforts to prevent
1. 2009 Spectrum estimates new infections 1.2 million
50
new HIV infections do not succeed. Therefore, monitoring treatment outcomes and the quality of life of
people living with HIV is essential. Many HIV-positive women need to manage their HIV status in combination with their higher susceptibility to cervical cancer and this poses additional challenges. It would be
an unjust situation if we fail to learn from the cost of neglecting TB and of keeping women alive on ARVs,
and then fail to prevent them from dying of cervical cancer. We should ensure that services for women
living with HIV are fully integrated, to address these risks. Furthermore, most adults still do not know their
HIV status (Universal Access Country Reports Trend Analysis, 2010) and, although easily preventable, rates
of mother-to-child transmission of HIV remain unacceptably high in many countries.
6.2.2 Virtual elimination of mother-to-child transmission of HIV
The transmission of HIV from mother-to-child during pregnancy, delivery or breast-feeding is entirely
preventable. Nevertheless, in 2009, an estimated 370 000 children younger than 15 years became newly
infected with HIV globally. Ninety-one per cent of these new infections occurred in sub-Saharan Africa
and 56 per cent in eastern and southern Africa alone. On average, countries in eastern and southern Africa have made remarkable progress in the prevention of mother-to-child transmission of HIV (PMTCT); in
2009, 68 per cent of pregnant women living with HIV received antiretroviral (ARV) medication to prevent
transmission. However, significant gaps exist between the delivery of interventions to the mother and
infants, with only 45 per cent of infants receiving ARVs. Furthermore, large variations exist across countries
and, even within countries, there are notable differences in the PMTCT coverage rate, regimens and the
quality of services being delivered. The adaptation of the 2010 WHO guidelines on PMTCT (World Health
Organization, 2010) has created new momentum towards phasing out the use of single-dose nevirapine
(NVP) and none of the countries in the region is currently basing a hundred per cent of their regimen protocol on single-dose NVP. However, the phasing-out rate varies across countries, related to health system
and human resource challenges.
The 2010 WHO PMTCT Guidelines emphasize the need to ensure that all pregnant women who are eligible
for treatment (i.e. those who have a CD4 count below 350) receive antiretroviral treatment for their own
health. If implemented, this will reduce maternal mortality, reduce transmission to infants and reduce infant
mortality, thus addressing Millennium Development Goals 4, 5 and 6.
Preventing HIV transmission from mothers to their babies requires a comprehensive package of services
that includes four prongs:
1. preventing primary HIV infection in women,
2. preventing unintended pregnancies in women living with HIV,
3. preventing transmission from pregnant women living with HIV to their infants, and
4. providing care, treatment and support for women living with HIV and their families.
Currently most interventions focus (and resources are used) almost exclusively on prong 3, providing treatment for the mother in order to prevent vertical transmission to infants. To have effective and efficient
programmes, all four prongs need to be addressed simultaneously. The provision of antiretroviral therapy
for all eligible pregnant women is the important fourth prong of comprehensive PMTCT programming
and this is a critical gap that needs to be addressed. Moreover, many programmes are funded through
development partners, causing considerable sustainability challenges given the absence of any significant
domestic resources directed towards comprehensive PMTCT programmes.
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Box 6.1 Tackling loss to follow-up through innovative approaches: Project

Mwana, Zambia
Since 2009, the Ministry of Health, in collaboration with partners, is using mobile phone technology to strengthen
health services in selected rural health facilities in three districts in Zambia. The focus has been on:
1. Reducing turn-around time for early infant HIV diagnosis by using SMS technology to send results from the central
testing laboratory to the clinics;
2. The establishment of a reminder system to contact mothers through SMS when the results are received in the clinic.
Since mid-June 2010 real time results have been sent from the laboratory to facility. The client reminder system has
also been set up, and training of health facility staff and community health workers has occurred. This innovative use of
mobile phone technology has the potential to reduce loss to follow-up and ensure the prompt initiation of treatment
for infants diagnosed with HIV.
About 80 per cent of women in our region access antenatal care services at least once during pregnancy
and this provides us with a real opportunity to provide them with a comprehensive package of services,
including PMTCT. However, loss to follow-up remains an immense challenge and, therefore, the critical
issue is to ensure that PMTCT services are available whenever and wherever women access antenatal care.
Often, this is not the case and pivotal opportunities are missed to reach women with quality interventions.
Project Mwana, piloted in five districts in Zambia, reduced loss to follow-up through speeding up delivery
of CD4 results to rural antenatal clinics and sending reminder short message service (SMS) text messages
to expectant mothers (See Box 6.1).
Meaningful involvement of male partners in PMTCT is of fundamental importance. A deliberate approach
should be created to establish a conducive policy and programme environment that promotes male
involvement through couples counselling and testing, in providing adherence support to their partners,
as well as provision of a package of services targeting men.
In Sub-Saharan Africa only 17 per cent of married women of reproductive age use a modern contraceptive
and a staggering 39 per cent of pregnancies in the region is unintended (The White Ribbon Alliance for
Safe Motherhood, 2010). Teen pregnancy rates continue to be high in the region and have not declined
significantly between 1990 (124 teen pregnancies per 1000 pregnancies) and 2007 (121 teen pregnancies
per 1000 pregnancies) (United Nations, 2010). Pregnant adolescents, regardless of their HIV status, have
special needs for care and support and need access to Maternal Neonatal Child Health services, including
family planning, to avoid unintended pregnancies.
6.2.3 Promote youth-friendly and gender-sensitive HIV testing and counselling
Across the region, governments and development partners have made substantial progress in scaling up
HIV testing and counselling (HTC) services, with a major increase in the number of facilities providing HTC
and many countries showing a three- to four-fold increase in services since 2006. The recent HIV testing
and counselling campaign in South Africa has shown that, of the total number of people tested, 65 per
cent were women. This suggests that much more work needs to be done to identify innovative ways to
encourage men and boys to participate. Despite some positive examples and efforts, in general the current reach of HIV testing services remains poor. In many countries in the region only 10 per cent of people
know their current HIV status from a recent test (Universal Access Country Reports Trend Analysis, 2010).
Even in settings in which HTC is routinely offered, the number of people who avail themselves of these
services remains low in many countries (WHO, UNAIDS and UNICEF, 2010). Recent data from a number of
countries suggest that, of those who avail themselves, adolescent girls and boys (aged 15 to 19) and young
women and young men (aged 20 to 24) account for 30 to 40 per cent of all HTC clients.
In 2009, there were just over 21 000 HTC sites in the region, conducting over 31 million HIV tests, and data
analysis points to the fact that almost twice as many girls were tested than boys in the region. While this
is a positive development, most of the HTC services have not been designed to be sensitive to the needs
of adolescents and young people and do not differentiate between the varying needs of adolescent boys
and girls and young men and women. Furthermore, the current structures provide very limited post-test
referral and follow-up psychosocial support services for adolescents who test positive.
Focus on the HTC experiences of adolescent girls and young women shows that many of them are only
provided with approximately 20 minutes of post-test counselling, based on protocols designed for adults,
52
which are often not sensitive to their needs. They are then referred to ART services for CD4 tests and, as
many of these girls and young women have only been recently infected with HIV, they may not be eligible
for treatment. Often, they are then told live positively and come back in six months. In many cases they
were not asked to return as soon as possible with their regular sexual partner, for couples counselling and
testing, nor were they referred to family planning and sexual reproductive health services. Frequently, after
testing, girls choose to live in silence or denial of their HIV status, rather than disclosing to their parents,
family members or caregivers that they have been sexually active and are also HIV-positive (and possibly
even pregnant). Young women who do disclose their HIV status to a spouse or regular partner often
experience recrimination, rejection, discrimination and even physical violence.
It is evident that the current HTC response in the region is missing an opportunity to reach more people by
becoming gender-friendly and tailored to adolescents and young people. With some minor adjustments
in the post-test counselling and referral system, these services could be made much more adolescentsensitive and youth-friendly. There is great potential to increase the provision of quality, differentiated,
post-test services which cater for couple counselling and to address the age and relationship context of
both HIV-positive and HIV-negative girls and young women.
6.2.4 Support HIV-positive adolescents
This year, in eastern and southern Africa, approximately 400 000 young people between the ages of 15
and 24 will become infected with HIV through unsafe sexual behaviours. Around 120 000 of these will
be adolescents between the ages of 15 and 19 (Universal Access Country Reports Trend Analysis, 2010).
Many of the HIV-positive adolescent girls face similar challenges related to gender as older HIV-positive
women, but encounter additional difficulties because of their young age. Moreover, with the emphasis
on virtual elimination of mother-to-child-transmission and the intensification of paediatric treatment programmes, the number of adolescents who were infected prenatally and are on treatment has increased
significantly. Overall, however, there is still a massive gap in support provided to adolescents living with
HIV in the region.
Box 6.2 Supporting HIV-positive adolescents in Botswana
Teen Club is a peer support group intervention for HIV-positive adolescents between the ages of 13
and 19. The mission of Teen Club is to empower HIV-positive adolescents to build positive relationships,
improve their self-esteem and acquire life skills through peer mentorship, adult role-modelling and
structured activities, ultimately leading to improved clinical and mental health outcomes, as well as a
healthy transition into adulthood. Partnering with organizations at the local level has allowed for the
decentralization of psychosocial care and support interventions for adolescents, namely Teen Club, to
various towns and villages throughout Botswana.
Adolescents, who are infected through unsafe sexual behaviour, face many challenges around living positively with HIV. Major issues are issues of confidentiality around their status, fear of stigmatization, rejection
and loss of friends. Disclosure to parents or caregivers is a much more serious issue for adolescent girls,
as current social norms promote sexual activity among males and chastity among females. Both females
and males face the challenge of having to disclose their HIV status to recent sexual partners. For sexually
active adolescent girls and young women, many are in age-disparate relationships, with around 40 per
cent of their partners aged five to nine years older, and another 20 per cent having partners more than
ten years older. A significant age gap creates relationship-power differentials which can affect disclosure.
Once disclosure takes place, there is a need for ongoing psychosocial support services to address issues of sexual and reproductive health and the provision of safe spaces to support healthy psychosocial
development. These issues are rarely addressed in clinical care services and, while adults have spaces in
which to talk and go for support, there are no ready and dedicated places for adolescents living with HIV.
Therefore there is a widespread need for the provision of ongoing psychosocial developmental support
in a non-health setting. Teen Club provides an example of a community-based HIV-positive adolescent
psychosocial support mechanism in Botswana (see Box 6.2 above). It is important to avoid creating or
fuelling stigma when providing psychosocial support.
53
For the increasing number of adolescents who were infected prenatally and are on treatment, their adherence support is another key consideration. Many adolescents who have been in treatment programmes
since infancy or early childhood begin to experience treatment fatigue against the backdrop and desire
to be normal like their peers. Many of these adolescents, who have aged out of paediatric service, do
not want to move to adult services which are not equipped to provide services tailored for adolescents
and young people. Preparing adolescents to move from paediatric or adolescent care to adult care is a
key challenge which will need to be addressed.
Although the number of adolescents living with HIV on treatment is quite small, there is a large cohort of
children, from the successful paediatric treatment programmes, which will be coming through the system.
Therefore, the system needs to incorporate effective protocols for ensuring that the age and sex differentiated developmental needs of adolescents are effectively addressed within paediatric and adult services.
The development of effective low-cost models for transitioning adolescents to adult care should be
integrated into national policy and programmes, with successful models documented and standardized,
so that they are taken to scale by multisectoral partners. Ideally, communities should contribute actively
to address stigma and normalize HIV as an avoidable chronic illness by promoting integrated services
which engage both HIV-positive and negative adolescents together around their developmental issues.
6.2.5 Invest in the continuum of care and the role of home-based care
HIV care and support demands a comprehensive set of services, including psychosocial, physical, socioeconomic, nutritional and legal care and support. These services are crucial to the well-being and survival
of people living with HIV and their caregivers, as well as orphans and vulnerable children. Care and support
services are needed from the point of diagnosis, throughout the course of HIV-related illness, regardless
of ability to access antiretroviral therapy (UNAIDS, 2010).
Women and girls often do not have sufficient access to comprehensive, evidence-based HIV and sexual
and reproductive health services. Prevention of mother-to-child-transmission (PMTCT) programmes are
usually the primary entry point for women to access HIV services. Women may face barriers due to their
lack of access to and control over resources, child-care responsibilities, restricted mobility and limited
decision-making power. Regarding men, males are subjected to social and gender norms and values that
may inhibit health-seeking behaviour due to a fear of stigma and discrimination, losing their jobs and of
being perceived as weak or unmanly (WHO Gender & HIV web site). Furthermore, referral mechanisms
between different medical, social and psychosocial services are often weak. Frequently, the first time a
woman or adolescent girl attempts to access a service becomes a pivotal benchmark for her consistent
future use of the service. Stereotyped HIV treatment for HIV-positive pregnant women may therefore
block health- and care-seeking behaviour of other pregnant women, regardless of their HIV status. There
is an urgent need to ensure that programmes become better capacitated to capture these clients and
provide services immediately.
The magnitude of the HIV epidemic places a massive demand on health systems. Few hospitals and clinics have sufficient resources or personnel to cope with the increased demand in services. It has become
imperative to look for practical and human solutions to the crisis in health care systems by drawing from
resources of families and communities.
Even though there is broad consensus that care (including HIV care and support) is a welfare responsibility
that should be provided by governments, caregiving largely relies on women volunteers. Across eastern
and southern Africa, unpaid, voluntary, informal networks of care providers have emerged as a critical
vanguard in the provision of care to sick people. As public health systems across the region face a barrage
of challenges, including under-capitalization, competing national priorities and an ongoing brain drain of
health care workers, the care providers, albeit with minimal support, are filling in the health care gaps. Many
care providers are invisible in the regional and global AIDS infrastructure. Furthermore, because unpaid
care work is usually done silently within the home, policy-makers often assume that there is a limitless
supply. Moreover, referral mechanisms between different medical, social and psychosocial services, on
the one hand, and between community-based care structures and government services, on the other
hand, are often non-existent or weak.
Given the dominant socio-cultural belief systems that values males and females differently and the subsequent gendered nature of work allocation, women and girls bear the brunt of caregiving in most com-
54
munities. Care, therefore, represents a triple burden for women who have to look after sick members in
their family, while fulfilling other roles at a time that they are either infected or affected by HIV. Moreover,
care is often an invisible contribution to the state, since the contribution is not reflected in the national
budgets. Attempts to estimate the economic value of caregiving revealed strong correlations between
unpaid work and the cycle of debilitating effects on women and children, since unpaid care can feminize
poverty (Bludlender, 2004). A recent study in Botswana concluded that, as the cost of providing care services to people living with HIV is very high, the government should substantially increase the allowances
paid to caregivers and the support it provides for the families of the clients. The overall costs for such a
programme would be lower, compared with significant budgets needed each year for health care and
for HIV and AIDS (Ama & Seloilwe, 2010).
Despite the challenging situation, there are positive developments in the region. The SADC Protocol on
Gender and Development article 27(c) requires all Member States to develop policies to address the issues
of care and women and girls. However, progress made towards this commitment is slow, with only a few
countries in southern Africa (GEMSA and VSO RAISA, 2010) having developed a comprehensive policy (see
Box 6.3 on Namibias pioneering home-based care policy). Care is evolving to include men and boys, albeit
at a slow pace. Civil society has spearheaded the involvement of men in care work with considerable levels
of success. However, most government policies and programmes are silent on how to involve men and
boys or how to intervene in breaking social stigma associated with male caregivers. Governments need to
take bold initiatives to stimulate male involvement in caregiving, by building on the existing work of civil
society, to grow the base of male caregivers and thereby lessen the overall burden of care.
Box 6.3 Namibias excellent comprehensive home-based care policy (CHBC)

The CHBC policy calls for a monthly incentive of N$ 250 to N$ 500 (roughly US$ 31 to US$ 62) and, under the new
policy, all caregivers will require an identity card, t-shirt, shoes, umbrella, a home-based care kit, some form of
transport, communication funds and a monthly monetary incentive. Under the new policy, the government will
re-train all caregivers using a standardized manual, and the government will accredit those who pass the training
through the Namibia Qualifications Authority. The policy attempts to address the psychological needs of caregivers.
In the draft guidelines, the Ministry of Health and Social Services requests that all CHBC organizations promote stress
management techniques to help caregivers adjust to the pace and approach to work, provide peer counselling and
establish a support network. The new policy acknowledges the gender disparity in care work and encourages the
involvement of men.
Care for vulnerable children is another dimension within the discussion around optimizing the continuum
of care. While there have been some notable successes for children affected by HIV over the last 10 years,
some statistics look depressingly familiar. At the end of 2010, an estimated 14.9 million children in subSaharan Africa lost one or both parents to AIDS. Research has also demonstrated that children, especially
girls, frequently take on the role of care when women are no longer available to provide care, resulting in
compromised development as they are likely to miss education and social development opportunities
(Opiyo, Yamano, & Jayne, 2008).
Despite the millions of dollars invested in children affected by AIDS, an average of only 11 per cent of
households caring for orphans and vulnerable children receive any form of external care and support
(WHO, UNAIDS and UNICEF, 2010). The debates are becoming increasingly urgent, with a second wave
of vulnerable children emerging as their grandparents are growing older and passing away. Rather than
being responsive, governments and development partners should be proactive. Supporting children
through families and in the care of families is widely considered as the preferable option (to, for example,
institutional care or individual support to children). This raises the question of how to provide incentives
for community or family care for vulnerable children. In contexts of high infection and prevalence rates
and many vulnerable children, cash or in-kind transfers are considered as options to reward families for
fostering vulnerable children. Social protection (particularly cash transfer programmes) has emerged as
a major response mechanism for families affected by HIV. There is compelling evidence that predicable
social transfers such as cash grants to vulnerable households enhance childrens nutritional status, improve
human capital and even increase lifetime earnings (Barrientos & DeJong, 2004) (Scott, 2009).
55
6.3 Recommendations
To ensure that momentum is maintained in the regional AIDS response, the following four recommendations are presented for further discussion and refinement.
6.3.1 Reform and expand HIV testing and counselling
Within the region, most of the HTC services have not been designed to be sensitive to the needs of adolescents and young people and do not differentiate between the varying needs of adolescent boys and
girls and young men and women. Current structures provide very limited post-test referral and follow-up
psychosocial support services for adolescents who test positive.
Therefore, the recommendation is to design and implement urgently a differentiated response to HIV
testing and counselling, making it gender-sensitive and youth-friendly, focusing on adolescent girls and
young women. Furthermore, the development of effective low-cost models for transitioning HIV-positive
adolescents to adult care should be integrated into national policy and programmes, documented and
standards developed, which can be taken to scale by a mix of partners.
6.3.2 Prioritize the care and treatment of HIV-positive pregnant women and girls
AIDS is a major driver of maternal mortality, especially in this region. In some countries, prior trends that
indicated improvements in maternal mortality have actually reversed, partly due to the impact of HIV. There
has been an alarming net increase in maternal mortality since 1994 (UNDP and UNAIDS, 2010). Within the
region, access to treatment for pregnant HIV-positive women for their own health remains low and the
majority of women in need are not accessing antiretroviral therapy. The root causes lie in weak health
systems, fragmented implementation and poor integration of services that fail to link programmes such
as prevention of mother-to-child transmission with treatment.
Therefore, the recommendation is to prioritize the care and treatment needs of all pregnant women who
are living with HIV, including adolescents, in policy, programming and budget allocations.
6.3.3 Strengthen support for the continuum of care
Women and girls in the region often do not have sufficient access to comprehensive evidence-informed
HIV and sexual and reproductive health services. Even though there is broad consensus that care is a
welfare responsibility that should be provided by governments, currently most HIV caregiving relies on
volunteerism. This has led to the creation of different models of care, and many are owned and run by civil
society organizations. Referral mechanisms between different medical, social and psychosocial services
and between community-based care structures and government services are often non-existent or weak.
Therefore, the recommendation is to establish intergovernmental and cross-party mechanisms and allocate budgets and track expenditure for effective coordination and collaboration on comprehensive care
and support, and to support and incentivize the continuum of care at community level and strengthen
linkages, referrals and integration of services at all levels.
6.3.4 Strengthen male involvement
Gender norms are not restricted to women and girls. They also affect boys and men. There is an urgent
need to acknowledge and address, in programming, the contributions that community and family carers
have made and continue to make in providing HIV care and support, and the fact that, due to gender
norms and stereotypes, the majority of caregivers are women and girls.
Therefore, the recommendation is to deliberately establish a conducive policy and programme environment that promotes male involvement, including strengthening couples counselling and testing, providing
adherence support to their partners and the provision of a package of services targeting men. Furthermore,
programmes and policies need to actively challenge gender stereotyping of male caregiving by promoting the involvement of men as carers, while also promoting the involvement of women in leadership and
decision-making roles in care provision.
56
6.4 Conclusion
Concerted efforts to combat HIV and AIDS are finally starting to show visible impact. However, as the
epidemic matures, a number of challenges increase simultaneously. AIDS-related illnesses remain an
important cause of death in the region and are projected to continue as a significant cause of premature
mortality in the coming decades (World Health Organization, 2009). AIDS continues to be a major development challenge and a global health priority, and the impact of the HIV epidemic on women, girls and
children is severe. The recent momentum and progress towards the virtual elimination of mother-tochild HIV transmission is very encouraging, although more needs to be done to build on this, including
ensuring that mothers are kept alive, by implementing all four prongs of PMTCT. The fundamental role of
home-based caregivers needs acknowledgement and support. Namibias comprehensive home-based
care policy provides a model for strengthening and supporting home-based care and this model could
be replicated and adapted for other settings. In addition, stronger coordination, resource allocation and
scaled up support is needed to strengthen the continuum of care. HIV testing and counselling should be
gender-sensitive and youth-friendly, and there is a need to strengthen post-testing psychosocial support
and facilitate the transition of HIV-positive adolescents from youth services to adult services, as needed.
Finally, more intensive efforts must be made to engage male involvement in family support and care,
including increasing their uptake of services and supporting gender transformation to strengthen HIV
prevention, treatment and care.
6.5 References
Ama, N., & Seloilwe, E. (2010). Estimating the cost of caregiving on caregivers for people living with HIV and AIDS in
Botswana: a cross-sectional study. Journal of the International AIDS Society, 13 (14).
Barrientos, A., & DeJong, J. (2004). Child poverty and cash transfers. Childhood Poverty Research and Policy Centre,
Save the Children.
Bludlender, D. (2004). Why Should We Care about Unpaid Work? Harare: UNIFEM.
GEMSA and VSO RAISA. (2010). Making Care Work Count: A Policy Handbook. GEMSA and VSO RAISA.
Opiyo, P., Yamano, T., & Jayne, T. (2008). HIV/AIDS and Home Based Health Care. International Journal for Equity in
Health, 1 (8).
Scott, J. (2009). Social Transfers and Growth in Poor Countries. In Promoting Pro-Poor Growth: Social Protection. Paris:
OECD.
The White Ribbon Alliance for Safe Motherhood. (2010). The White Ribbon Alliance: Atlas of Birth. The White Ribbon
Alliance for Safe Motherhood.
UNAIDS. (2010). Getting to zero: 2011-2015 Strategy of the Joint United Nations Programme on HIV/AIDS (UNAIDS).
Geneva: UNAIDS.
UNAIDS. (2010). Outlook Report. GENEVA: UNAIDS.
UNDP and UNAIDS. (2010). The AIDS and MDGs Approach: What it is, why does it matter, and how do we take it
forward? New York: UNDP and UNAIDS.
UNICEF ESARO. (2011). Analysis from UN, DHS and MICS data across the region (eastern and southern Africa).
unpublished.
United Nations. (2010). The Millennium Development Goals Report 2010. New York: United Nations.
Universal Access Country Reports Trend Analysis. (2010). Universal Access Country Reports Trend Analysis.
Unpublished.
WHO Gender & HIV web site. (n.d.). http://www.who.int/gender/hiv_aids/en/. Retrieved from WHO: http://www.who.
int/gender/hiv_aids/en/
WHO, UNAIDS and UNICEF. (2010). Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health
sector, Progress Report 2010. Geneva: WHO, UNAIDS and UNICEF.
57
World Health Organization. (2010). Antiretroviral drugs for treating pregnant women and preventing HIV infection in
infants: recommendations for a public health approach. Geneva: WHO.
World Health Organization. (2010). Antiretroviral therapy for HIV infection in adults and adolescents: recommendations
for a public health approach: 2010 Revision. WHO.
World Health Organization. (2009). Global Health Risks; mortality and burden of disease attributable to selected major
risks. Geneva: WHO.
Engaging men as partners in addressing gender inequality and HIV
Engaging men
as partners in
addressing gender
inequality and HIV
7.1 Introduction
It has long been recognized that unequal relationships between men and women and societal norms of femininity and masculinity are significant influences
on the HIV epidemic. This is particularly important as HIV is most often transmitted sexually. Power imbalances between women and men cover all aspects of
personal, social and economic relations, from access to education and property
rights, to the negotiation of condom use.
Research and statistics highlight the importance of gender inequality in driving the
pandemic, as well as the interaction between gender inequality and other social
and structural factors such as economic status, ethnicity and religion that can influence disease dynamics. Gender, itself, is a structural driver of HIV for women and
girls, heterosexual men and boys, as well as for men who have sex with men, and
transgender people. Indeed, gender is an intrinsic component of the HIV and AIDS
response.
Women and girls often bear a disproportionate burden of responsibility for families
affected by HIV. In many contexts, orphaned girls are more vulnerable to mistreatment than orphaned boys. Women widowed as a result of AIDS are more likely to
suffer economic exploitation and less likely to be able to replace lost family income.
Gender norms and expectations also make men vulnerable to HIV, for example, by
influencing male sexuality and risk-taking, and making men and boys less likely to
seek medical care when ill or when they test positive for HIV.
From the perspective of identifying successful interventions, it is important to take
into consideration the fact that boys and men, like women and girls, are not a homogenous group (UNDP, 2010). The experiences, positions and attitudes of boys
and men vary widely, even among men in the same community. At the same time,
despite the diversity of individual boys and men, there are prevalent gender norms
for men, or masculinities, that dictate a limited and often harmful set of roles and
behaviours for men. These gender norms interact with gender identity and sexuality
to set the context of HIV risk and vulnerability. For example, dominant interpretations of what it means to be a man in many societies be strong, successful, sexually active, heterosexual and privileged over women are in direct opposition to
behaviours, ideas and beliefs that are more gender equitable, safer and lower risk
in terms of HIV transmission.
Galvanizing efforts to tackle the twin issues of HIV and gender inequality, particularly
gender-based violence, is especially timely in light of the UN Secretary-Generals
UNiTE to End Violence against Women Campaign, the Millennium Declaration and
58
59
the 2015 deadline of the Millennium Development Goals (MDGs). The UNAIDS family and UN Women have
articulated renewed and intensified commitment to addressing these issues in the Agenda for Accelerated
Country Action for Women, Girls, Gender Equality and HIV (UNAIDS, 2010), commonly called The Agenda for
Women and Girls.
The Agenda for Women and Girls emphasizes the importance of continued political commitment to gender equality and womens empowerment as essential in and of themselves, as well as being key elements
to address the drivers of HIV. Noting that these commitments continue to be articulated unequivocally,
achievements on the ground still remain too limited. It acknowledges that traditional and stereotypical
views of women and men and girls and boys hinder an effective HIV and AIDS response. The engagement
of men and boys in the implementation of this Agenda for Women and Girls is therefore critical. Men and
women must work together for gender equality, by questioning harmful definitions of masculinity and
ending all forms of gender-based violence, i.e. violence against women and girls as well as against men
and transgender people. Changes in mens and boys attitudes and behaviours, and changes in unequal
power between women and men are essential to prevent HIV in women and girls.
7.2 Factors underlying women and mens vulnerabilities to HIV
Successful work with men for gender equality and HIV prevention hinges on understanding dominant
gender norms for men and women, how they are entrenched in societies, how they interact with sexuality
(known as heteronormativity1), and how these norms help divide power and resources unequally between
women and men and among different groups. It also requires understanding the gendered patterns of
the HIV pandemic. When HIV began to spread around the world, the majority of infections were among
males. The 1990s witnessed a rapid increase in the number of women living with HIV in sub-Saharan Africa. There was also an increase in infections among women in other parts of the world, albeit at a slower
pace and from a smaller base. By 2001, nearly half of all adults living with HIV were women. Today, slightly
more than half of all people living with HIV are women and girls, although such global averages mask
important differences among and within countries (UNAIDS, 2010). Significantly, some key affected groups
are disproportionately men who are drug users, incarcerated, clients of sex workers, and men who have
sex with men, and/or with women sex workers.
In sub-Saharan Africa, women make up about 61 per cent of all adults with HIV (UNAIDS, 2007). In younger
age groups, girls and young women are particularly vulnerable and represent an even larger proportion of
people living with HIV. This reflects patterns in some settings of intergenerational sex, most often involving
older men and younger women, and earlier age of sexual debut for females.
Outside sub-Saharan Africa, the majority of HIV infections in most countries continue to be among males,
although females account for a slow but steadily increasing proportion of new HIV infections in many
settings. Depending upon the country, key risk factors for men include unprotected sex: with sex workers;
sex with other men; injecting drugs or some combination of the three. In most countries outside Africa,
the most significant risk factors for women are relationships with men involved in these risky activities, or
direct participation in selling sex or injecting drugs. Transgender people and incarcerated men, while representing a small proportion of overall populations, are almost always disproportionately affected by HIV. 2
Gender-based violence is also closely associated with HIV risk. Evidence shows that persistence of genderbased violence, and the lack of social and legal remedies and redress for violence also drive HIV and hinder
AIDS responses. Gender-based violence or the threat of such violence may restrict womens ability
to negotiate risk reduction and engage in safer sexual practices. It can limit womens abilities to seek HIV
testing, treatment, care or support, and can hinder them from disclosing their HIV status. Men and boys
can also be targets of gender-based violence, especially when their behaviour or presentation does not
conform to community norms of masculinity.
1. As a term, heteronormativity describes the processes through which social institutions and social policies reinforce the belief that human beings fall into two distinct sex/
gender categories: male/man and female/woman. This belief (or ideology) produces a correlative belief that those two sexes/genders exist in order to fulfill complementary
roles, i.e., that all intimate relationships ought to exist only between males/men and females/women. To describe a social institution as heteronormative means that it
has visible or hidden norms, some of which are viewed as normal only for males/men and others which are seen as normal only for females/women. (Graduate School
of Syracuse University, 2004)
2. Transgender people are individuals whose gender expression and/or gender identity differs from conventional expectations, based on the physical sex they were born
into. Transgender is an umbrella term that is often used to describe a wide range of identities and experiences. Because it is an umbrella term, it is often thought to be an
imprecise way of describing the particulars of specific identities and experiences. (Accessed at web.mit.edu/hudson/www/terminology.html.)
60
Just as gender norms and expectations influence relationships between males and females, they often play
a role for key populations such as men who have sex with men, transgender individuals etc. For example,
a 2006 study in South Asia concluded that:
Male-to-male sex and sexualities in Bangladesh and India, to a large extent, do not fit the
heterosexual/homosexual oppositional paradigm that is commonly used as a discourse to discuss
same-sex behaviours. Rather, the primary pattern appears to be that of a gendered framework,
orientation and sex roles This led to an understanding that the issue of feminization, as much
as that of sexual practice, can itself lead to violence, abuse and harassment (Naz Foundation
International, 2006).
Gender norms often discourage men from seeking health services and decrease the likelihood that they
will access HIV testing or treatment services until they are already very ill (Hudspeth, Venter, Van Rie, Wing,
& Feldman, 2004) (Coetzee, et al., 2004). Across the region, men underutilize HIV services. In South Africa,
men access antiretrovirals (ARVs) at half the rate of women, get tested at one third of the rate of women
and have lower CD4 counts at initiation of treatment (Hudspeth, Venter, Van Rie, Wing, & Feldman, 2004).
In Botswana, 52 per cent of women and 44 per cent of men had tested for HIV. In Swaziland, 25 per cent
of women had tested, compared to 18 per cent of men. Such low utilization by men of critical HIV services
compromises mens health. This also impacts women, increasing the likelihood that their male sexual partners do not know their HIV status and get tested late with already compromised immune systems, leaving
them with a heavy burden of HIV care. Mens low and late utilisation of testing and treatment services is
also costly for public health facilities and places additional strain on public health systems tasked with
resuscitating male patients with severely compromised immune systems.
Thus, while it is widely known that gender inequality and rigid gender norms compromise womens health
and increase their vulnerability to HIV and violence, it is less well recognised that these same gender norms
are also detrimental to mens health. A number of studies conclude that contemporary gender roles encourage men to equate risky sexual behaviour with manliness and, conversely, to regard health-seeking
behaviour as unmanly. All too often, contemporary gender roles encourage boys and men to equate
the use of violence, alcohol and substance, the pursuit of multiple sexual partners and the domination of
women with being manly. Studies show that men have far more sexual partners than women and often
have multiple concurrent partners, placing both themselves and their partners at high risk for infection.
Studies also show that traditional gender roles lead to more negative condom attitudes and less consistent
condom use and promote beliefs that sexual relationships are adversarial (Noar & Morokoff, 2002). Men are
also far more likely to drink heavily than women, with South African men likely to be habitual heavy drinkers, according to the 2002 World Health Report (World Health Organization, 2002). Alcohol consumption
is a risk factor for gender-based violence and for the sexual disinhibition that contributes to the spread of
HIV and AIDS (Shisana & Simbayi, 2002).
To improve HIV outcomes, it is then essential that policies and programmes recognise and respond to the
reality that womens health is integrally linked to mens health-related attitudes, practices and opportunities. It follows that gender and human rights programming must endeavour to reduce mens risk taking
practices and increase mens utilisation of critical HIV services.
A recent article in The Lancet makes the case that HIV testing and treatment services are currently failing
too many men with dire implications for womens health:
Efforts to understand mens health-seeking behaviour are poorly understood in the AIDS
epidemic, and encouraging men to get tested and into treatment is a major challenge, but one
that is poorly recognized. Effectively addressing these issues means moving beyond the phase of
laying blame and starting to develop interventions to encourage uptake of prevention, testing,
and treatment for men for everyones sake. (Mills, Ford, & Mugyenyi, 2009)
61
While interventions are required that provide HIV-sensitive services to survivors of violence, efforts to
prevent violence are also essential. In this context, engaging men and boys for gender equality is a crucial
HIV prevention measure. However, programming has not yet reached the scale, depth or breadth required
to reverse the epidemics of gender-based violence and of HIV, nor have they effectively integrated men
and boys in efforts to challenge and change harmful gender norms. Programmes have not put the issues
of masculinity at the centre of consideration.
7.3 Changing gender norms
Transforming harmful gender norms that increase womens and mens risk and vulnerability to HIV requires
programming to empower women and men and promote their engagement in AIDS responses. Simultaneously, transformative interventions must call traditional masculinities into question as fluid and open to
change. Effective policies and programmes rely on challenging male gender norms and engaging men and
boys as responsible actors in changing these practices that reinforce unequal power and discrimination
against women. Effective programmes explore and challenge dominant notions of masculinity, educate
men and boys on sexual and reproductive health (including the prevention of gender-based violence),
and encourage men to support womens rights and empowerment (UNDP, 2010).
The current level of resources for responding to gender inequality, HIV and gender-based violence is still
inadequate to support the scale-up and replication of promising programmes. Increased resources are
required to engage in operational research, to expand the evidence base on such programmes, and to
understand more fully and act upon mens and boys involvement in addressing gender-based violence
and gender inequality. Lack of investment in national strategies to address structural drivers of gender
inequality and of violence (in general and in the context of HIV) has resulted in a fragmented approach.
Interventions are generally small-scale projects operating without the benefit of a sound, unifying, national
strategy and with limited investment in evaluation. Gender and human rights-responsive programming is
hampered by an exclusive focus on women and girls, at times in isolation from male partners, family and
community members. This limits the impact of programmes and policies.
Research increasingly provides evidence that policies and programmes that focus on engaging men
and boys in reducing gender inequality and in altering harmful gender norms work best when they address behaviours and attitudes that perpetuate gender inequality and support rigid gender norms. This
means closely examining and addressing processes of socialization of men and women, as well as the
cultural practices and structural forces that underpin the gendered aspects of HIV and AIDS, including
the following:

factors that drive men to engage in different forms of violence;
structure, identity and agency in terms of both perpetrators and victims of violence;
norms and factors that encourage men to engage in high-risk practices that compromise their own
and their partners health and those that discourage them from accessing health services;
cultural practices and structural forces that limit women and mens access to critical HIV services, including the gendered assumptions embedded in health policies and services that sometimes serve
as barriers to uptake of services; and
political and institutional processes that divide the private and public spheres, including changing
social roles, expectations and responsibilities of men and women.
Changing norms that uphold traditional masculinity and unequal power between women and men is
essential to changing the course of the HIV epidemic. Men and boys can be engaged to challenge gender
norms by taking on caregiving responsibilities, supporting their partners participation in HIV services and
by getting tested and treated for HIV themselves, by preventing gender-based violence, by supporting
the leadership of women and by championing womens rights in public (UNDP, 2010). Men who hold
leadership positions in political and economic arenas, as well as men who are leaders in social, cultural and
religious life, can also be actively engaged in the elimination of violence against women and girls. These
and other such actions will not only influence policy and programme development, but also a new generation of young men. In order to be gender-transformative, programmes need to encourage men and boys
62
to support women in achieving gender equality goals as well as support community norms, social capital
and other factors that can influence a shift away from or rejection of violence among men and women.
A recently issued policy brief from the World Health Organization outlines the rationale for using policy approaches to engage men in achieving gender equality, reducing health inequities and improving womens
and mens health. It proposes a framework for integrating men into policies that aim to reduce gender
inequality and health inequities; and highlights some successful policy initiatives addressing men that
have advanced gender equality and reduced health inequities by generating positive changes in mens
behaviours and relations with women and with other men (Flood, Peacock, Barker, Stern, & Greig, 2010).
Among other recommendations, this brief encourages national policy makers to develop policies and
programmes that:

address the relationship between alcohol and violence and HIV risk;
integrate gender equality education into medical male circumcision roll-out strategies;
increase mens involvement in care activities, especially caring for children affected by HIV and AIDS;
and
maintain the political will needed to engage men and boys in achieving gender equality.
Moreover, despite the fact that changing gender norms is a long-term endeavour, some progress can be
achieved in real time. A World Health Organization (WHO) and Instituto Promundo study (World Health
Organization, 2007) revealed that well-designed interventions with men and boys can produce shortterm changes in attitude and behaviour. It also found that the programmes that show evidence of being
gender-transformative seem to result in more success in changing behaviour among men and boys.
7.4 Review of programmes that engage men in addressing gender and HIV
Worldwide, there are many organizations that engage men and boys to address issues of masculinities and
gender equality. On the global level, the MenEngage Alliance is a coalition of NGOs and UN agencies that
formed in 2004 to promote the engagement of men and boys in achieving gender equality, promoting
health and reducing violence at the global level, including questioning the structural barriers to achieving gender equality3. In Africa, MenEngage has a regional Steering Committee and has established active
country networks in South Africa, Mozambique, Tanzania, Ethiopia, Kenya, Sierra Leone, Zimbabwe, Zambia,
the Democratic Republic of Congo and Rwanda. MenEngage also supports community-based outreach
programmes, which can be effective transformative strategies when they address risky behaviours that
fuel HIV and make the connection between the harmful effects of both violence against women and HIV
(UNDP, in press).
One good example of this type of initiative is the Stepping Stones programme, which uses group discussion and education in community settings regarding gender norms, sexuality, associated risk behaviour
and HIV. Implemented in 100 countries worldwide, with a growing community of practice of more than
900 members, Stepping Stones4 provides the most rigorous evidence that addressing gender norms in the
context of HIV and AIDS programmes can reduce violence. An evaluation of the Stepping Stones initiative
in South Africas Eastern Cape by the South African Medical Research Council (MRC) showed significant
changes in mens attitudes and practices. With two years' follow-up, participants reported fewer partners,
higher condom use, less transactional sex, less substance abuse and less intimate partner violence (Jewkes,
et al., 2008) (Jewkes, Wood, & Duvvury, submitted).
Engender Healths Men As Partners programme has also brought about significant changes in mens
involvement in prevention of mother-to-child transmission (PMTCT) programmes, leading to a 46 per cent
increase in men testing with their partners and 87.6 per cent increase in the number of men joining their
3. See www.menengage.org. The Alliances International Steering Committee Members include Sonke Gender Justice Network (co-chair),Promundo (co-chair), International
Center for Research on Women, EngenderHealth, Family Violence Prevention Fund, the International Planned Parenthood Federation, Save the Children-Sweden, Sahoyog,
the White Ribbon Campaign and Mens Resources International, Mens Resources International (United States), Salud y Genero (Mexico), the Athena Network, WHO, UNFPA,
UNDP and UN Women. At the national level, members include more than 400 NGOs from sub-Saharan Africa, Latin America and the Caribbean, North America, Asia and
Europe.
4. http://www.steppingstonesfeedback.org/
63
partners for PMTCT visits. Greater male involvement in PMTCT has been shown to improve outcomes for
women and children.
The Sonke Gender Justice Network in South Africa also supports men in advocating for gender equality.
Their One Man Can Campaign supports men to take active stands against domestic and sexual violence,
promote and sustain change in their personal lives to protect themselves and their partners from HIV and
AIDS, and work towards changing gender norms that drive the rapid spread of HIV. One Man Can workshop
activities and materials help men to take action in their own lives and in their communities, to promote
healthy relationships based on a commitment to gender equality and healthy models of masculinity. An
impact evaluation of the One Man Can Campaign found significant changes in self-reported short-term
behaviour in the weeks following project activities, with 25 per cent of participants getting tested for HIV
and 61 per cent men reporting an increase in condom use. About half reported that they had witnessed
gender-based violence (GBV) in their home or community and the majority of them reported it so that
action could be taken: more than 52 per cent reported GBV to the police; 28 per cent to community structures; and six per cent to local NGOs. More than four out of five participants of the One Man Can campaign
also reported having subsequently talked with friends or family members about HIV and AIDS, gender and
human rights. Importantly, the One Man Can Campaign also educates men about existing gender and HIV
related laws and policies and supports them to work with women to monitor government compliance,
with its commitments to ending gender-based violence and addressing HIV and AIDS.
Another effective method to improve attitudes and, to some extent, behaviour related to violence and
HIV is mass media edutainment campaigns, which are entertainment programmes designed to educate
as well as amuse. Edutainment campaigns can provoke reflection about harmful, inequitable attitudes
and behaviours related to masculinities by personalizing risk via identifiable characters, and by reinforcing
messages through on-going storylines. Two examples, Puntos de Encuentro in Central America and Soul City
in Southern Africa use television dramas, radio programmes, and information packets to promote gender
equity as well as reduce violence and HIV risk. Evaluation of Puntos de Encuentro found increased support
for gender equity; increased communication about HIV, intimate partners and sex; greater sense of capacity
to solve problems related to domestic violence; and increased condom use in some groups (Solrzano,
Bank, Pea, Espinoza, Ellsberg, & Pulerwitz, 2008). An extensive population-based impact evaluation of
Soul City showed that it had reached 86 per cent of the population, leading to a ten per cent decrease
of those who view intimate partner violence as a private issue and a slight increase in viewers likelihood
to report abuse (Scheepers, 2001) (Scheepers & Cristophides, 2001) (Usdin, Christofides, Malepe, & Maker,
2000) (Singhal, Usdin, Scheepers, Goldstein, & Japhet, 2004) (Bott, Morrison, & Ellsberg, 2005).
There is growing evidence about the effectiveness of programmes that address gender inequality, discrimination, and violence against women and girls and HIV in other words, interventions that challenge
the structures that drive both gender inequality and HIV. Effective programmes seek to change societal
norms that discriminate against women and girls, exacerbate marginalization and condone violence, and
aim to create safer sexual environments and more equitable social environments. Critically, this includes
changing norms of masculinity as well as femininity through the engagement of men and boys as
partners in a gender-transformative HIV response.
However, short-term gains can be achieved in selected areas of service provision, such as enhanced HIV
testing services, ensuring access to sexual and reproductive health services, comprehensive post-rape care
services, male engagement, and economic empowerment. The optimal solution in any given environment
is to have a combination of actions addressing both long-term and short-term goals.
Structural interventions work because they alter the context in which health or ill-health is produced.
They can address socio-economic conditions, the legal and policy context and social and cultural norms
of gender (including ideas about appropriate feminine and masculine roles). Structural interventions also
stress linkages between sexual and reproductive health and HIV policies, programmes and services.
64
7.5 Recommendations
Although further research needs to be done to identify more precisely and comprehensively the strategies
that work for incorporating men and masculinities in HIV and AIDS prevention and treatment, common
lessons across programmes have emerged. Based on these lessons, policies and programmes should
endeavour to incorporate the following:5
7.5.1 Acknowledge how social constructions of masculinities contribute to HIV.
This includes carrying out national household level research on mens attitudes and behaviours, using such
instruments as the International Men and Gender Equality Survey (IMAGES) and the Gender Equitable Men
(GEM) Scale. Such information can provide powerful inputs to drive and monitor policy-level responses
and to monitor changes.
7.5.2 Include an analysis of transforming inequitable gender norms as they relate to men and
women in national AIDS plans and policies.
Tanzanias national AIDS programme, for example, has a detailed plan and recommendations for engaging
men and acknowledging how an understanding of masculinities can improve HIV programming.
7.5.3 Develop policies and programmes to increase mens utilization of HIV services,
especially HIV testing and treatment, including multi-pronged mass media and community
education strategies.
7.5.4 Scale up and disseminate results of gender-transformative programming that has shown
evidence of effectiveness.
Good practice case studies should be provided on programmes for HIV prevention, increasing male uptake
of HIV services and testing, and increasing mens participation in caregiving. Learning needs to be shared
in an open manner to strengthen policy and practice.
7.5.5 Carry thorough gender and vulnerability analyses at national and local levels to
understand how gender norms and power structures leave specific groups of women and men
more vulnerable to HIV.
Analyses should pay special attention to the specific vulnerabilities of men who migrate for work, incarcerated men, men who have sex with men (MSM) and men in the military.
7.5.6 Promote partnerships between national AIDS programmes and strategies and civil
society groups working with men, including non-heterosexual men.
For example, some countries have formed networks between NGOs working specifically in HIV and AIDS
and GBV prevention and the small but growing number of NGOs working with men from a gender perspective. Links could also be strengthened between national AIDS programmes and MenEngage country
networks.
7.5.7 Ensure that work to engage men are supportive of and not counter to efforts to
empower women and girls.
While it is key to make gender visible in the lives of men and to acknowledge how men and boys are made
vulnerable by rigid gender norms, it also vital to bear in mind the greater power and income that men
have collectively, compared to women in most of the world. It is also important that efforts be made to
engage men and boys, so that they advance gender equality and champion womens rights.
5. These recommendations are from Men, Masculinities and HIV/AIDS: Strategies for Action (UNDP, in press)
65
7.5.8 Promote joint prevention programming that engages women, men, girls and boys.
Increasingly, programme planners are acknowledging the need for gender strategies that engage women,
men, boys and girls together.
7.5.9 Support programmes that promote the rights of a range of gender identities.
Various projects, such as those by the Naz Foundation, incorporate a human rights-based approach to HIV
programming, with a particular emphasis on reduction of stigma and discrimination of men who have
sex with men and transgender people. These programmes are reported to have helped increase condom
use, reduce rates of STI infection and increase access to HIV and STI services (International HIV/AIDS Alliance, 2003). However, no data is available on the extent to which empowerment of MSM contributed to
this success.
7.6 Conclusion
Building solidarity between men and women toward gender equality and poverty alleviation is instrumental to curbing the HIV epidemic. In order to be gender-transformative, programmes need to encourage
men and boys to work alongside women and support them in achieving their goals. As this paper has
shown, there are many examples of good practice in engaging men as partners in addressing gender
equality and HIV, including increasing mens uptake of HIV prevention, treatment and care services, addressing gender-based violence, taking responsibility for HIV prevention for themselves, their partners
and families, and in actively promoting gender equity and equality. Policy-makers and planners need
to ensure that there is an enabling environment to support effective structural interventions and social
and behaviour change (SBCC) programmes. As the evidence shows, effective SBCC programmes seek to
change norms of masculinity as well as femininity, in order to engage men and boys (and women and
girls) as active partners in achieving an effective, gender-transformative HIV response.
7.7 References
International HIV/AIDS Alliance. (2003). Between men: HIV/STI prevention for men who have sex with men. Hove:
International HIV/AIDS Alliance.
Bott, S., Morrison, A., & Ellsberg, M. (2005). Preventing and Responding to Violence against women in Middle- and LowIncome Countries: a Global Review and Analysis. Washington DC: World Bank.
Coetzee, D., Hildebrand, K., Boulle, A., Maartens, G., Louis, F., Labatala, V., et al. (2004, April 9). Outcomes after Two
Years of Providing Antiretroviral Treatment in Khayelitsha, South Africa. AIDS, 18 (6), pp. 887895.
Flood, M., Peacock, D., Barker, G., Stern, O., & Greig, A. (2010). Policy approaches to involving men and boys in achieving
gender equality. Geneva: WHO.
Graduate School of Syracuse University. (2004). Interrupting Heteronormativity. Syracuse: Graduate School of
Syracuse University.
Hudspeth, J., Venter, W., Van Rie, A., Wing, J., & Feldman, C. (2004). Access to and early outcomes of a public South
African antiretroviral clinic. The Southern African Journal of Epidemiology and Infection, 19 (2), pp. 4851.
Jewkes, R., Nduna, M., Levin, J., Jama, N., Dunkle, K., Puren, A., et al. (2008, August 7). Impact of Stepping Stones
on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial.
British Medical Journal, 337.
Jewkes, R., Wood, K., & Duvvury, N. (submitted). I woke up after I joined Stepping Stones: meanings of a HIV
behavioural intervention in rural South African young peoples lives. Social Science & Medicine.
Mills, E. J., Ford, N., & Mugyenyi, P. (2009, July 25). Expanding HIV care in Africa: making men matter. The Lancet, 374.
Naz Foundation International. (2006). from the Front Line: A report of a study into the impact of social, legal and judicial
impediments to sexual health promotion, care and support for males who have sex with males in Bangladesh and
India. Naz Foundation International.
66
Noar, S., & Morokoff, P. J. (2002). The Relationship between Masculinity Ideology, Condom Attitudes, and Condom
Use Stage of Change: A Structural Equation Modelling Approach. International Journal of Mens Health, 1 (1).
Scheepers, E. (2001). Soul City 4 Impact Evaluation Violence Against Women Volume I. Houghton: Soul City.
Scheepers, E., & Cristophides, N. (2001). Soul City 4 Impact Evaluation Violence Against Women Volume II. Houghton:
Soul City.
Shisana, O., & Simbayi, L. (2002). Nelson Mandela/HSRC study of HIV/AIDS: South African national HIV prevalence,
behavioural risks, and mass media household survey. Cape Town: Human Sciences Research Council.
Singhal, A., Usdin, S., Scheepers, E., Goldstein, S., & Japhet, G. (2004). EntertainmentEducation Strategy in
Development Communication. In C. Okigbo, & F. Eribo (Eds.), Development and Communication in Africa. Boston:
Rowman and Littlefield.
Solrzano, I., Bank, A., Pea, R., Espinoza, H., Ellsberg, M., & Pulerwitz, J. (2008). Catalyzing individual and social
change around gender, sexuality, and HIV: Impact evaluation of Puntos de Encuentros communication strategy in
Nicaragua. Washington DC: Population Council.
UNAIDS. (2007). AIDS Epidemic Update: December 2007. Geneva: UNAIDS.
UNAIDS. (2010). Report on the Global AIDS Epidemic. Geneva: UNAIDS.
UNDP. (2010). Fast Facts: HIV, Gender, Health and the Millennium Development Goals. New York: UNDP.
UNDP. (2010). Guidance Note: Addressing HIV, gender inequality and gender based violence, including the needs and
rights of women and girls, in strategies, plans and programmes. New York: UNDP.
UNDP. (in press). Men, Masculinities and HIV/AIDS: Strategies for Action. New York: UNDP.
Usdin, S., Christofides, N., Malepe, L., & Maker, A. (2000). The Value of Advocacy in Promoting Social Change:
Implementing the New Domestic Violence Act in South Africa. Reproductive Health Matters, 8 (16), pp. 5565.
World Health Organization. (2007). Engaging men and boys in changing gender-based inequity in health: Evidence from
programme interventions. Geneva: World Health Organization.
World Health Organization. (2002). World Health Report 2002: Reducing risks, promoting healthy life. Geneva: WHO.
Annex 1
Annex 1. Draft
Windhoek Declaration
on Women, Girls
Gender Equality and
HIV: Progress towards
Universal Access
Draft Windhoek Declaration
Women, Girls Gender Equality and HIV:
Progress towards Universal Access
6 8th April 2011
Safari Conference Centre, Windhoek, Namibia
PREAMBLE
WHEREAS the year 2011 marks 30 years since the first case of AIDS was identified;
AND WHEREAS 10 years have passed since the landmark United Nations General
Assembly Special Session on HIV/AIDS was held in 2001;
NOTING that in 2006, countries made the commitment to achieving Universal Access to HIV prevention, treatment, care and support;
CONCERNED that 30 years into the epidemic, women and girls account for 60 per
cent of those living with HIV in Sub-Saharan Africa, and further concerned that 76
per cent of young people aged 1524 years living with HIV are female;
NOTING THAT national surveys show that young women in aastern and southern
Africa are up to six times more likely to be infected than their male counterparts;
due to a combination of biological, behavioral, and structural causes, which render
women and girls powerless to refuse sex or negotiate safer sex;
ACKNOWLEDGING that the adaptation and implementation of the UN Millennium
Development Goals, in particular MDG 3 on gender equality and womens empowerment; MDG 4 on child mortality; MDG 5 on maternal health, and MDG 6 on halting
and reversing the spread of HIV, provide an effective way to galvanise action and
bridge the gender, development, health and equality gaps;
UNICEF/ Leonie Marinovich
67
68
Annex 1
FURTHER ACKNOWLEDGING that the concerns of women and girls need high level and consistent advocacy and that Members of Parliament play a critical role in accelerating efforts;
AFFIRMING that African leaders have committed to implementing a number of regional and international
instruments related to HIV and gender equality;1
FURTHER AFFIRMING that the following principles should guide the implementation of the recommendations included in this declaration:

Aligning to national priorities;
Meaningfully and measurably involving civil society, especially people living with HIV and key populations, including people with disabilities;
Respecting, promoting and protecting human rights and gender equality;
Relying on approaches that are evidence based, technically sound and built on the best available
scientific evidence and technical knowledge;
Promoting harmonization and integration of efficient and effective scaled-up responses to HIV and
AIDS that integrate prevention, treatment, care support, SRH; and
Engaging community gatekeepers, such as traditional and religious leaders;
NOW THEREFORE, we the delegates to the Technical meeting on Women, Girls, Gender Equality and HIV
from SADC, COMESA and EAC in Windhoek, Namibia declare that:
1. All national planning processes must clearly demonstrate the integration of the concerns of women,
girls, gender equality and HIV and include demonstrable, costed, programmatic actions to address
them;
2. Countries should commit to robust, sex- and age-disaggregated data collection and analysis and to
setting new, ambitious, clearly disaggregated Universal Access targets. This will facilitate stronger
targeting and prioritization towards interventions that have meaningful impact for women, girls and
gender equality;
3. Countries should demonstrate how budgets are being allocated and spent on programmes for
women, girls, gender equality and HIV and develop key performance indicators on gender-sensitive
responses. In so doing, they should commit to the 2015 timeframe of meeting the 15 per cent Abuja
Commitment for health and urgently commit to developing finance sustainability strategies for their
HIV responses;
4. Countries should commit to paying urgent attention to the particular needs of young women and
adolescent girls as well as to the concerns of key populations such as LGBTI communities, sex workers and other marginalized groups;
5. Countries should commit to furthering research (including operational research) on programmes to
better understand the vulnerability of and impact on women and girls and address gender equality
and HIV;
6. Countries should protect and promote the human rights of women and girls; and pay special attention to marginalization and social exclusion, including people living with HIV;
1. These include the Beijing platform for action; CEDAW; ICPD; The Gaborone declaration on the road map Towards Universal access to Prevention, Care and treatment,
the Brazzaville commitment on scaling up towards Universal Access; The Abuja Call for Accelerated Action Towards Universal Access to STI/HIV/AIDS, Tuberculosis and
Malaria Services in Africa; the protocol on Rights of women in Africa (2003); The Solemn Declaration on Gender Equality in Africa (2004); SADC Protocol on Gender and
Development (2008); Sexual Reproductive Health and Rights plan of Action(Maputo plan of Action 2006);
69
Annex 1
We recommend further action should be taken in the following specific seven (7) thematic areas:
1. HIV Prevention, Women, Girls, and Gender Inequality
1.1. Countries should urgently commit to reducing new infections among women and girls, in particular
among young women, as part of meeting the EAC and SADC targets of halving the number of new
infections by 2015;
1.2. Countries should commit to collecting gender- and age-disaggregated data through robust surveillance systems and social assessments, to better track sources of new infections;
1.3. Countries should commit to providing access to scientifically proven prevention strategies, in
particular female-controlled prevention methods, while effectively making maximum use of the
effective prevention strategies currently available (e.g. female condoms);
2. Sexual and Reproductive Health and HIV
2.1. Countries should mobilize resources to accelerate the full integration of SRH and HIV within all
health facilities and pay particular focus to the development of adolescent-friendly policies, and
guidelines and scaling up services;
2.2. Countries should commit to prioritizing comprehensive sexuality education within families, communities and in and out-of-school settings, while ensuring that facilitators of such training are
adequately equipped to provide quality sexuality education;
2.3. Countries should commit themselves to addressing the sexual reproductive health rights of women
and girls, including the peculiar concerns of women living with HIV;
2.4. Countries should ensure that national HIV plans, strategies and programmes fully integrate gender
and sexual and reproductive health rights;
3. Treatment and Care and the Concerns for Women and Girls
3.1 Countries should ensure a robust continuum of care and reduce the burden of care on women and
girls, particularly facilitating support to home-based care programmes;
3.2 Countries should urgently scale up voluntary, gender-sensitive and youth-friendly HIV Testing and
Counselling services, including couple HTC, targeted where HIV is highest and ensuring that these
services are optimally linked with treatment and prevention services, especially for those who are
most at risk;
3.3 Countries should urgently scale up access to HIV treatment, through local production and pooled
procurement, and guarantee uninterrupted access to nutrition, ARVs and full diagnostic services
especially for adolescents, pregnant HIV positive women and their infants;
3.4 RECs should urgently commit to a strategy by 2015 to implement local production and bulk procurement of ARVs and related commodities by Member States, through pooled procurement and
using domestic resources;
4. Adopting a Multi-stakeholder Approach to Address Violence Against Women and HIV
4.1 Governments should commit to urgently addressing existing gaps within legal frameworks and
address the conditions that perpetuate risk to gender-based violence and HIV transmission and that
prohibit the full realization of sexual and reproductive health of all women and girls;
4.2 Governments should commit to demonstrating leadership and take action to promote zero tolerance to GBV while prioritising access to agreed comprehensive GBV and HIV-related services;
4.3 Countries should strengthen GBV monitoring systems including in post-crisis situations and RECs
should develop strong, transparent mechanisms for country peer review and monitoring of progress in addressing violence against women;
70
Annex 1
5. The Law, Gender and HIV
5.1 Countries should harmonise and address contradictions between statutory law and customary
practices that perpetuate gender inequality, with clear and well resourced processes of implementation, social mobilization and community participation;
5.2 Countries should promote legal literacy and provide affordable and accessible legal services to
women, people living with HIV, people with disabilities, people with diverse sexualities and other
key populations and should commit to translating legal and policy frameworks into simplified and
local languages, using easily accessible IEC tools and materials;
5.3 Countries should urgently commit to addressing laws that criminalize HIV transmission, same-sex
relations and sex work;
5.4 Countries should commit themselves to convene a special Parliamentary session every year, which
will deal with the issues relative to laws and rights of women living with HIV, children and gender
equality;
6. Enabling Environment Measures and Mechanisms Necessary for Effective Universal
Access to Comprehensive Prevention, Treatment Care and Support
6.1 Countries should commit to creating visionary leadership on women, girls, gender equality, and HIV
for high level advocacy, guided by the UNAIDS Agenda for Accelerated Country Action for Women,
Girls, Gender Equality and HIV;
6.2 Countries and Regional Economic Commissions should ensure standardized health care protocols
and health system and community systems strengthening to address the needs of women and girls;
6.3 Countries should intensify their efforts in modifying harmful cultural practices which predispose
women and girls to HIV infection and violence;
7. Engaging Men as Partners in addressing Gender inequality and HIV
7.1 Countries should develop strategies with specific gender indicators to increase mens support for
women and children (HTC, PMTCT, GBV, HIV treatment and care) and their own access and utilization
of HIV, health and SRH services as part of the national HIV response;
7.2 Countries should scale up gender-transformative programming, with diverse groups of men and
boys, which is supportive of womens empowerment from a human rights perspective;
7.3 Promote strategic partnerships between organizations working with men and women to collectively develop advocacy and community mobilization strategies to engage men for gender equality
and prevention of HIV and GBV.
Dated: 8th April 2011

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Looking towards 2015:

2. The law, gender and HIV

3. Sexual and reproductive health, gender and HIV:

4. HIV prevention, women, girls and gender equality

5. Adopting a multi-stakeholder approach to

6. HIV treatment and care: the concerns for women

7. Engaging men as partners in addressing gender

Annex 1. Draft Windhoek Declaration on Women, Girls,

Acronyms and abbreviations

ad interim (temporary, acting)

Acronyms and abbreviations

International Men and Gender Equality Survey

Monica Tabengwa, expert in human rights training and research, democracy

1.1 Strategic recommendations

1.1.4 Brothers and sisters for life

The law, gender and HIV

The law, gender

The law, gender and HIV

2.2 International legal frameworks for women, girls and HIV

The law, gender and HIV

2.3 Key challenges and ways to address them

4. You can also find commentary at http://www.africafiles.org/article.asp?id=18881

The law, gender and HIV

Box 2.1 Working with cultural structures to facilitate access to justice to

The law, gender and HIV

The law, gender and HIV

2.3.3 Punitive laws and policies

2.3.4 Violations of the right to bodily integrity

The law, gender and HIV

2.4 Guiding principles for future action

The law, gender and HIV

2.4.1 Increasing womens access to justice and participation in decision-making

The law, gender and HIV

The law, gender and HIV

2.5.4 Protecting the right to bodily integrity

The law, gender and HIV

The law, gender and HIV

The law, gender and HIV

Sexual and reproductive health, gender and HIV

Sexual and reproductive

3.2 International agreements

Sexual and reproductive health, gender and HIV

3.3 African legal instruments

3.4 The Maputo Plan of Action

Sexual and reproductive health, gender and HIV

3.5 Review of progress since Maputo

Sexual and reproductive health, gender and HIV

HIV, STI, Malaria and SRH

Many countries have integrated

The main challenges reported are weak health systems,

Strengthened communitybased STI/HIV/AIDS and

Many countries have plans in

Communities, including youths and men, should be involved

Many countries have supportive

This requires skilled human resources, social and behaviour

Youth-friendly SRHR services

Nearly two-thirds of countries

Although most countries have policies and strategies in

Many countries have strategies

Because abortion is generally criminalized, back-street

Access to quality Safe

Road maps for the reduction of

Providing adequate services including regular supplies